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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604171
Report Date: 05/29/2025
Date Signed: 05/29/2025 10:11:45 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
08/02/2022 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20220802160403
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: 67DATE:
05/29/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Executive Director Jonathan WheelerTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Neglect resulted in a Stage 4 (four) pressure injury
Staff did not meet resident’s incontinence care needs
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 allegations. LPAs identified themselves and discussed the purpose of the visit with Executive Director Jonathan Wheeler.

On August 2, 2022, Community Care Licensing (CCL) received a complaint alleging staff neglect of Resident 1 (R1) (R1 – see LIC811 Confidential Names List) resulted in a Stage 4 (four) pressure injury and staff did not meet R1’s incontinence care needs. Physician’s Report dated September 27, 2019, confirmed R1 was diagnosed with Multiple Sclerosis (MS) and had a bladder/bowel impairment. R1’s Individual Service Assessment dated February 10, 2022, also established that R1 had a history of skin breakdown and a record of yeast rashes in groin area. The assessment also stated that R1 will receive physical assistance with bathing two times per week and staff will monitor R1 for skin redness, openings, or abnormalities. Lastly, the assessment revealed that R1 was receiving urinary catheter care from an outside source agency.
Substantiated
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)
Page: 1 of 6
Control Number 08-AS-20220802160403
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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According to the first allegation, on July 30, 2022, R1 was observed to have a Stage 4 (four) pressure ulcer on the left buttocks while being treated for an unrelated urinary catheter issue. Based on staff statements, on July 30, 2022, Staff 1 (S1), Staff 2 (S2) and Staff 3 (S3) were walking the facility patio when S1 observed a catheter bag on the ground. S1 and S2 believed the bag belonged to R1 and proceeded to R1’s room, where it was found that R1 was missing such catheter bag. R1 explained to staff that the catheter had been leaking but was unaware the bag was missing. Staff proceeded to contact outside source agency that provided catheter care and was instructed to contact emergency personnel for assistance. According to S1, prior to emergency personnel arriving, S1 and S2 cleaned/wiped R1’s groin area and whole body, while not observing any irregularities with skin. Medical records collected revealed once R1 arrived at hospital, it was found that R1 had a Stage 4 (four) gangrenous pressure ulcer to left buttocks. According to interview with Administrator, no staff was aware that R1 had developed a pressure injury. Interview with multiple staff revealed that R1 was known to be refusing care since May of 2022 and care records corroborated such information. Interview with Administrator confirmed that Administrator was aware of R1 refusing care and did not take action to prevent such issues. 

It was also alleged that R1 was not assisted with incontinence care for bowel movements. Interviews with multiple staff revealed that R1 was refusing bowel incontinence care from staff. Records collected revealed that as of May 25, 2022, R1 had a change in condition, and required assistance with activities of daily living (ADSL), was bed bound, and forgetful. Documentation shows that these changes were also documented on June 8, 2022, and July 15, 2022, with additional information that R1 was defecating in bed, wheelchair, and shower. Interview with S1 revealed that R1 was denying staff from entering room and often hiding feces throughout the shared cottage. Administrator could not provide documentation that such changes and behaviors were reported to R1’s Physician and/or family.  

Based on staff and outside source interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation that staff neglect of R1 resulted in a Stage 4 (four) pressure injury and staff did not meet R1’s incontinence care needs. The allegations are therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). 
 
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)
Page: 6 of 6
Control Number 08-AS-20220802160403
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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The Department has determined this violation resulted in injuries to the resident in care.  An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM.  Currently, per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division. An exit interview was conducted with Executive Director Jonathan Wheeler, and a Plan of Correction was jointly developed. A copy of this report, LIC811, LIC 9099-Cx2, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Executive Director Jonathan Wheeler, signature on this form confirms receipt of documents. 
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)
Page: 2 of 6
Control Number 08-AS-20220802160403
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: 05/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/30/2025
Section Cited
CCR
87468.2(a)(8)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ...residents in privately operated residential care facilities for the elderly shall have ...the following personal rights:(8) To be free from neglect. This requirement was not met as evidence by:
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Licensee will provide staff with a vendorized traiing in regards to self neglect and skin assessments. Licensee will provide proof of training scheduled within 24 hours.
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Based on interviews and record reviews the licensee did not protect resident from neglect in 1 of 67 persons in care (R1) which posed an immediate safety risk to persons in care.
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Type B
06/13/2025
Section Cited
CCR
87625(a)(1)(C)
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87625 Managed Incontinence (a)The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following....: (1).... managed with any of the following: (C) A program of scheduled toileting at regular intervals.

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Licensee will provide staff with a vendorized training in regards to incontinence care.
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Based on interviews and record reviews the licensee did not provide resident with managed incontince program in 1 of 67 persons in care (R1) which posed an 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: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
08/02/2022 and conducted by Evaluator Iby Strong
COMPLAINT CONTROL NUMBER: 08-AS-20220802160403

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: DATE:
05/29/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Executive Director Jonathan WheelerTIME COMPLETED:
09:30 AM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Licensee did not seek medical care for resident.
Licensee retained a resident with a prohibited health condition without an exception.
INVESTIGATION FINDINGS:
1
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3
4
5
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7
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9
10
11
12
13
Licensing Program Analysts (LPA) Iby Strong and Hannah Rodgers conducted an unannounced visit to deliver findings in the above complaint allegations. LPAs identified themselves and discussed the purpose of the visit with Executive Director Jonathan Wheeler.

On August 2, 2022, Community Care Licensing (CCL) received a complaint alleging licensee did not seek medical care for Resident 1 (R1) (R1 – see LIC811 Confidential Names List) and licensee retained a resident with a prohibited health condition without an exception. Physician’s Report dated September 27, 2019, confirmed R1 was diagnosed with Multiple Sclerosis (MS) and had a bladder/bowel impairment. R1’s Individual Service Assessment dated February 10, 2022, also established that R1 had a history of skin breakdown and a record of yeast rashes in groin area. The assessment also states that R1 will receive physical assistance with bathing two times per week and staff will monitor R1 for skin redness, openings, or abnormalities.
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)
Page: 4 of 6
Control Number 08-AS-20220802160403
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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According to the first allegation, on July 30, 2022, R1 was believed to have a leaking and malfunctioning urinary catheter for two days and facility staff did not seek medical attention for R1. According to records collected, R1 was receiving urinary catheter care from an outside source agency. Interviews with staff revealed that on July 30, 2022, Staff 1(S1), Staff 2 (S2) and Staff 3 (S3) were walking the facility patio when S1 observed a catheter bag on the ground. S1 and S2 believed the bag belonged to R1 and proceeded to R1’s room, where it was found that R1 was missing such catheter bag, R1 explained to staff that catheter had been leaking but was unaware the bag was missing. Staff proceeded to contact outside source agency that provides catheter care and was instructed to contact emergency personnel for assistance. R1 was taken by emergency personnel on the same date of incident. Records collected revealed that R1 had a visit by outside source agency medical professional and had a urinary catheter change on July 29, 2022.  

It was also alleged that as of July 30, 2022, facility licensee knowingly retained a resident with a prohibited condition Stage 4 (four) pressure ulcer without an exception from the Department. Interview with S1 and S2 established that care staff were unaware of R1’s pressure injury. Interview with Administrator revealed R1 has refused care since May 2022, and had not allowed staff to provide care or make observations of resident’s physical conditions. Records collected did not confirm R1 was diagnosed with pressure injury until July 30, 2022.  Interview with outside source medical professional revealed that a pressure injury on R1 had not been observed during regular care or reported by R1. 
 
Based on interviews, and record reviews the preponderance of evidence standard has not been met, therefore the allegations are unsubstantiated. 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)
Page: 5 of 6