374604171-5-29-2025-08-AS-LTEZ-DH6NQC-20250530103940

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604171
Report Date: 05/29/2025
Date Signed: 05/29/2025 10:09:24 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
12/12/2023 and conducted by Evaluator Iby Strong

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20231212085832

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: 67	DATE:	05/29/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Executive Director Jonathan Wheeler		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Physical abuse to resident by facility staff resulted in serious bodily injuries.

INVESTIGATION FINDINGS:

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

On December 13, 2023, Community Care Licensing (CCL) received a complaint alleging physical abuse to Resident 1 (R1) by facility staff resulted in serious bodily injuries.

Physician’s Report dated November 14, 2023, states R1 is diagnosed with mild neurocognitive impairment and is ambulatory. Facility records also show R1 moved into the facility on November 17, 2023.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

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-20231212085832

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: 05/29/2025

NARRATIVE

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During the investigation, the Department collected pertinent resident records, outside source records and conducted various interviews. According to details of the allegation, R1 reported that on December 11, 2023, Staff 1(S1) lifted and threw R1 during an emergency evacuation at the facility causing fractures to multiple ribs. Medical records confirmed that on December 12, 2023, R1 was diagnosed with fractured ribs. Interview with S1 revealed that S1 did not assist R1 in the evacuation on December 11, 2023, and S1 was focused in extinguishing the fire in a residents’ room. Interview with Staff 2, who was also present on the date of the incident, revealed R1 was not assisted out of the facility as R1 is ambulatory. Records collected revealed that R1 was later found with a fire lighter and cardboard on the date of the fire and was considered a suspect of arson to the facility.

During further interviews it was found that on December 9, 2023, R1 had an outburst where R1 urinated on the floor of the facility, destroyed holiday decoration and hit Staff 3 (S3) and Staff 4 (S4). Interview with S3 and S4 revealed R1 slapped S3 and punched S4; attempts of S4 to intervene in further violence on S3 and residents, resulted in S4 and R1 slipping on the urine-soaked floor, causing S4 to fall on top R1. S4 believes the fall may have caused R1’s fractured ribs. After the incident, S3 and S4 assessed R1 for injuries and R1 reported to be fine. Records collected confirmed R1 has assaulted multiple staff and destroyed facility property. Interview with an outside medical source established that facility attempted to protect R1 from self and others and injuries may have not been an act of abuse. Further interviews revealed that R1 has a history of chest pain, and according to Staff 5 (S5), R1 reported having chest pain as of December 6, 2023. Interview with R1 established that R1 believed their ribs were injured as of the first incident on December 9, 2023.

Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove physical abuse to resident by facility staff resulted in serious bodily injuries. 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: 05/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

LIC9099 (FAS) - (06/04)

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