374604171-3-25-2025-08-AS-JROO-DFTTGJ-20250417144313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604171
Report Date: 03/21/2025
Date Signed: 03/25/2025 08:19:23 AM

Unsubstantiated

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
12/24/2024 and conducted by Evaluator Iby Strong

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20241224160823

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: 68	DATE:	03/21/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director Jonathan Wheeler		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Neglect and/or Lack of supervision resulted in resident-on-resident altercation with injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Jonathan Wheeler.

On December 24, 2024, Community Care Licensing (CCL) received a complaint alleging staff neglect and/or lack of supervision resulted in resident-on-resident altercation with injury. Allegation states that on December 23, 2024, Resident 1 (R1) and Resident 2 (R2) had a physical altercation that resulted in swelling to the head and laceration to R1.

Physician’s Report dated September 18, 2024, states R1 is diagnosed with a major neurocognitive disorder and does not require continuous bed care. R2’s Physician Report dated September 18, 2024, shows R2 is considered confused and disoriented but has no aggressive behaviors. R1 care records show R1 has a history of verbal and physical aggression with other residents but no history with R2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20241224160823

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: 03/21/2025

NARRATIVE

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During the investigation, through record reviews, and interviews, the Department established the following sequence of events. Based on staff statements, on December 23, 2024, at or around 4pm, R1 was heard calling R2 derogatory names then R2 hit R1 in the face, which resulted in a cut and bruising to R1’s face. According to multiple staff, R1 and R2 were separated and R1 was provided first aid while emergency personnel arrived. At this time, R1 was taken to receive medical care and R2 was sent to a psychiatric hold for a safety evaluation. While both residents were away, Wellness Coordinator requested R1 and R2’s Primary Care Provider to re-evaluate both resident’s medications but such changes were denied. On the same night of the incident, both R1 and R2 were discharged back to the facility. On this date, there were three staff present to intervene in the incident, provide first aid and contact emergency personnel. According to outside source records, on this date R1 was diagnosed with an abrasion to the forehead and contusion of the forehead.

The investigation also found that on December 24, 2024, at or around 4pm, R1 was heard calling R2 the same derogatory names and R2 hit R1 in the face multiple times. Staff present established that the altercation was heard, and multiple staff assisted in separating the two residents. On this date, emergency personnel were contacted but only medical assistance arrived. R1 was then taken to receive medical care. Outside source records collected revealed that this incident resulted in R1 having a cut to the scalp as well as a hematoma, but no fractures were found. According to interview with the Wellness Coordinator R1 and R2’s rooms are now in different parts of the same building; their meals are served in different locations and there is additional supervision to both residents. R2 has since received medication to assist with agitation.

Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove staff neglect and/or lack of supervision resulted in resident-on-resident altercation with injury. An exit interview was conducted with Executive Director Jonathan Wheeler, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC9099 (FAS) - (06/04)

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