374604171-9-25-2025-08-AS-LTEZ-DM224P-20250930170415

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604171
Report Date: 09/25/2025
Date Signed: 09/25/2025 04:52:46 PM

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
02/09/2023 and conducted by Evaluator Iby Strong

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20230209083323

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: 66	DATE:	09/25/2025
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Clinical Director Yolanda Torres and Director Jonathan Wheeler		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Lack of supervision resulted in injury
Neglect resulted in pressure injuries
Facility retained resident with a higher level of care needs
Staff did not address resident's change in condition while in care
Staff did not ensure that resident stayed hydrated while in care
Staff did respond to requests for assistance by resident in a timely manner
Staff did not ensure that resident had clean clothing
Staff did not ensure that resident's hygiene needs were met
Staff did not ensure that resident's toileting needs were met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings on the above-mentioned allegations. LPA met with Clinical Director Yolanda Torres and Director Jonathan Wheeler and discussed the purpose of the visit.

On February 9, 2023, Community Care Licensing (CCL) received the following complaint allegations regarding Resident 1’s (R1) care received. During the investigation LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews.

Resident 1’s records collected revealed R1 is a diagnosed with a mild- cognitive impairment, has a history of skin breakdowns, can follow instruction and is able to use a walker for mobility. Additional records revealed R1 was only at the facility for a total of eight days. According to the first allegation, on the fourth day of stay, R1 sustained an unwitnessed fall which resulted in bruising. Interviews with staff did not reveal any information to corroborate that R1 was not treated for unwitnessed fall. Interview with residents present during the time of the incident revealed that facility staff respond to residents timely.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

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-20230209083323

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: 09/25/2025

NARRATIVE

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R1’s Physician Report established that R1 does not require continuous monitoring or continuous bed care
According to the second allegation, neglect to R1 resulted in multiple stage 1 and stage 2 pressure injuries to genital area and ankle. Facility records revealed R1 was admitted with a quarter size scab to the ankle. Records also revealed that R1 has a history of skin breakdown prior to admission. Staff interviews did not reveal any information to corroborate that R1 was neglected resulting in pressure injuries.
The third allegation states facility retained R1 who required a higher level of care. Records collected revealed facility conducted a pre-admission appraisal and found R1 to be at facility’s level of care available. Physician report dated January 16, 2023, did not show any restricted or prohibited diagnosis. Interview with staff revealed there were no issues with the level of care required by R1.
According to the fourth allegation, the facility did not address R1’s ten-pound weight loss while in care. Records were unable to confirm R1 lost the weight during the eight day stay at the facility. Interview with staff could not corroborate that R1 was not monitored or R1’s changes were not identified during R1’s stay.
According to the fifth allegation, R1 was not given enough fluids resulting in dehydration. Interview with multiple staff revealed residents are given water or juice throughout the day in addition to the beverage with their meals. Interview with other residents reveal residents are provided with numerous drinks throughout the day. There were no records documenting R1 as dehydrated.
The sixth allegation states facility staff were not responding timely to call button. Interview with staff could not establish that facility was not responding timely to call button. Records collected could not establish facility staff were not responding timely to residents in need. Interview with residents revealed that they are assisted within a few minutes of requesting assistance.
The seventh allegation states R1 was not provided with any clean clothing. Interview with laundry staff revealed that laundry is done regularly and there is one full time employee conducting laundry service. Interview with residents revealed that they do have full laundry service. LPA Strong observed laundry service and confirmed such information.
According to the eighth allegation, R1 was only fully showered one time during R1’s stay. Interview with staff revealed that residents also receive sponge baths as well as showers. Interview with residents established that facility staff provide residents with bi-weekly showers or sponge baths depending on resident. Interview with staff could not establish that facility staff only provided R1 with one shower during stay.
Lastly is was alleged that R1 was not assisted with toileting needs. Interview with staff could not establish that R1 was not assisted with toileting. Interview with residents established that they are changed frequently or assisted to the restroom when requested. There were no records available to corroborate allegation.
Based on interviews, records available and observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Clinical Director Yolanda Torres and Director Jonathan Wheeler to whom a copy of this report, and the Licensee/Appeal Rights were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

LIC9099 (FAS) - (06/04)

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