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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604171
Report Date: 08/01/2025
Date Signed: 08/01/2025 02:55:00 PM

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
05/15/2023 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230515112520
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: 66DATE:
08/01/2025
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Clinical Director Yolanda TorresTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Physical abuse that resulted in serious injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Clinical Director Yolanda Torres.

On May 15, 2023, Community Care Licensing (CCL) received a complaint alleging Staff 1 (S1) physically assaulted Resident 1 (R1) (R1 – see LIC811 Confidential Names List) which resulted in a fractured nose. Physician’s Report dated March 6, 2023, confirmed R1 was diagnosed with a major neurocognitive disorder and has aggressive behaviors. R1’s Individual Service Assessment dated December 21, 2021, also established that R1 required encouragement, reassurance or interventions regarding mental status.

Details of the allegation state that on May 13, 2023, at approximately 10:06pm, S1 struck R1 in the face, resulting in a fractured nose and a black eye. Interview with multiple staff revealed that earlier on that date, S1 had ordered pizza for the staff and R1 had asked for a piece. S1 proceeded to deny R1 any of their food and R1 became verbally aggressive.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
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 3
Control Number 08-AS-20230515112520
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: 08/01/2025
NARRATIVE
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Interview with S2 revealed that at around 10pm, R1 proceeded to ask S1 for pizza again, and S1 declined his request. At this time R1 became more verbally aggressive and S1 clocked out of their shift and went outside. According to Staff 2, minutes later, S1 came back into the building and told S2, “I hit him”, referring to R1. Interview with lead MedTech revealed that S1 told MedTech that R1 hit S1 so S1 hit them back. On May 14, 2023, emergency personnel interviewed S1 who revealed that during the incident, R1 swung at S1, S1 dodged the attempted hit then struck R1 with an open right hand to the nose in self-defense, which cause R1 to fall to the floor. Medical records collected revealed that on May 14, 2023, R1 was admitted to hospital due to facial trauma and diagnosed with a nasal fracture. On June 1, 2023, S1 was interviewed by the Department. S1 stated that they were being assaulted by R1, and in self-defense put out right arm, which cause R1 to hit nose on S1’s arm. Interview with another resident revealed that S1 has a history of verbal outbursts towards residents in care.  

Based on interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation that staff assaulted resident in care, resulting in serious injury. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). 

The Department has determined this violation resulted in injuries to the resident in care.  An immediate Civil Penalty is being charged and is noted as a duplicate violation within 12 months, therefore it is assessed as $1,000 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 Clinical Director Yolanda Torres, and a Plan of Correction was jointly developed. A copy of this report, LIC811, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Clinical Director Yolanda Torres, signature on this form confirms receipt of documents. 
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20230515112520
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: 08/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2025
Section Cited
CCR
87468.2(a)(8)
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87468.2 a)... All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 8)To be free from verbal, mental, physical, or sexual abuse.
This requirement was not met as in evidence:
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Licensee had a personal rights training in May of 2025. Due to duplicate violation within 12 month, POC considered cleared.
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Based on interviews and records collected the licensee did not protect R1 from physical abused in 1 of 57 residents in care which posed an immediate Safety 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: 08/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3