Inspection Reports for Lo-Har Senior Living
768 Dorothy St, El Cajon, CA 92019, United States, CA, 92019
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with licensing requirements. However, the facility had multiple substantiated deficiencies over time, primarily related to resident care issues such as neglect resulting in a Stage 4 pressure injury, failure to assist with activities of daily living, medication administration errors, and staff abuse including physical assault and inappropriate conduct toward residents. Enforcement actions included civil penalties totaling at least $1,100 and citations for immediate safety risks, particularly concerning abuse and elopement incidents. The most recent report from October 17, 2025, was clean with no deficiencies cited, showing improvement compared to earlier reports with more frequent issues. Overall, while the facility has had serious concerns in the past, recent inspections suggest conditions have improved.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 68
Capacity: 68
Deficiencies: 0
Oct 17, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be in compliance with all licensing requirements. The environment was safe and well-maintained, with no deficiencies cited during the visit.
Report Facts
Non-ambulatory residents allowed: 41
Hospice waiver residents allowed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yolanda Torres | Clinical Director | Met with Licensing Program Analyst during inspection and discussed visit purpose |
| Iby Strong | Licensing Program Analyst | Conducted the unannounced required annual inspection |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 68
Deficiencies: 1
Sep 25, 2025
Visit Reason
An unannounced Case Management visit was conducted to follow up on multiple incidents reported to Community Care Licensing, including a verbal altercation between a resident and staff and an incident of incorrect medication administration.
Findings
One deficiency was issued related to medication administration where the licensee failed to assist a resident with self-administration of medication, posing a potential safety risk. No adverse reactions to the medication error were reported.
Complaint Details
The visit was complaint-related following reports of a verbal altercation between Resident #1 and Staff 1, and an incident where Resident #2 was issued a lower dose of medication than prescribed. The verbal altercation was partially substantiated based on staff statements; the resident was no longer present for interview. The medication error was reported to required entities with no adverse reactions noted.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee did not assist resident with self-administration of medication in 1 of 66 persons in care, posing a potential safety risk. | Type B |
Report Facts
Deficiencies cited: 1
Census: 66
Total capacity: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan Wheeler | Director | Named in relation to the verbal altercation and exit interview |
| Yolanda Torres | Clinical Director | Named in relation to the verbal altercation, medication error, and exit interview |
| Iby Strong | Licensing Program Analyst | Conducted the inspection visit |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 68
Deficiencies: 0
Sep 10, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 02/08/2022 regarding resident injury during transfer, lack of assistance with incontinence care, and unmet dietary needs.
Findings
The investigation included interviews and record reviews which found no preponderance of evidence to substantiate the allegations. The resident's bruise cause was not linked to staff, incontinence care was provided as required, and dietary shakes were regularly given with one noted delivery delay.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations included resident injury during transfer, failure to assist with incontinence care, and failure to meet dietary needs. Interviews and records did not confirm these allegations.
Report Facts
Capacity: 68
Census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Yolanda Torres | Clinical Director | Interviewed via telephone during investigation |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 66
Capacity: 68
Deficiencies: 0
Aug 1, 2025
Visit Reason
An unannounced Case Management visit was conducted to follow-up on two incidents reported to Community Care Licensing involving alleged rough treatment of a resident and a medication administration issue.
Findings
No deficiencies were cited during the visit. An internal investigation found no abuse in the reported incident, and staff have been retrained on medication management with plans for ongoing audits and shadowing.
Complaint Details
The visit was complaint-related, following reports of alleged rough treatment of Resident #1 by staff and a medication error involving Resident #2. The abuse allegation was not substantiated, and no adverse effects resulted from the medication incident.
Report Facts
Incident report date: May 25, 2025
Incident report date: Jul 1, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yolanda Torres | Clinical Director | Met with Licensing Program Analyst during visit and provided information on investigations and corrective actions |
| Iby Strong | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Jonathan Wheeler | Administrator/Director | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 68
Deficiencies: 1
Aug 1, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 05/15/2023 alleging physical abuse by staff resulting in serious injury to a resident.
Findings
The investigation substantiated that Staff 1 physically assaulted Resident 1, causing a fractured nose and black eye. The incident was confirmed by interviews, medical records, and other evidence, resulting in a cited deficiency and an immediate civil penalty.
Complaint Details
The complaint was substantiated. Staff 1 was found to have physically assaulted Resident 1 on May 13, 2023, resulting in serious injury including a fractured nose. The investigation included interviews with staff and emergency personnel, review of medical records, and corroborating evidence.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect resident from physical abuse, violating residents' personal rights to be free from verbal, mental, physical, or sexual abuse. | Type A |
Report Facts
Civil penalty amount: 1000
Resident count: 66
Facility capacity: 68
Plan of Correction due date: Aug 5, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation. |
| Yolanda Torres | Clinical Director | Facility representative involved in exit interview and plan of correction. |
| Kandy Ducharme-Franklin | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 68
Deficiencies: 0
Aug 1, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that the facility was not returning representative communication attempts.
Findings
The investigation found no evidence to support the allegations; telephone and email communications were functioning properly, and the email address in question belonged to a former employee. Therefore, the allegations were unsubstantiated.
Complaint Details
The complaint alleged that the facility was not returning representative communication attempts. The investigation concluded the allegations were unsubstantiated based on interviews and observations.
Report Facts
Capacity: 68
Census: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation |
| Yolanda Torres | Clinical Director | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 68
Deficiencies: 0
Jul 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-06-20 regarding neglect resulting in hospitalization, inadequate supervision, unmet laundry needs, and lack of a food service director at the facility.
Findings
The investigation found that the resident with alleged neglect was able to self-propel their wheelchair and staff appropriately notified the medical provider, who determined hospitalization was unnecessary. Staffing was adequate based on acuity levels. The facility had no designated food service director but employed a person responsible for food planning and service. Laundry needs were generally met with staff aware of service needs and hiring additional staff. The allegations were deemed unsubstantiated based on interviews and records review.
Complaint Details
The complaint alleged neglect resulting in hospitalization, inadequate supervision, unmet laundry needs, and lack of a food service director. The investigation concluded the allegations were unsubstantiated.
Report Facts
Capacity: 68
Census: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jonathan Wheeler | Executive Director | Facility representative met during investigation and exit interview |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 68
Deficiencies: 0
Jul 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2023-02-06 regarding multiple allegations about resident care and facility operations.
Findings
The investigation was unable to prove or disprove the allegations, and the findings were determined to be unsubstantiated after a review and telephone conference with the current administrator.
Complaint Details
The complaint included allegations that staff did not provide residents with housekeeping, did not properly launder residents' clothing, did not safeguard residents' belongings, and did not meet residents’ dietary needs. The findings were unsubstantiated.
Report Facts
Facility capacity: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Teutschel | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and telephone conference |
| Johnathan Wheeler | Administrator | Met with during investigation; noted as not the administrator at the time the complaint was filed |
| Stacy Barlow | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 68
Deficiencies: 0
Jun 26, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint alleging that staff did not assist a resident with incontinence care.
Findings
The investigation found no preponderance of evidence to substantiate the allegation. Interviews with staff, residents, and outside sources did not confirm the incident, and no related staff terminations were verified.
Complaint Details
The complaint alleged that an unidentified staff refused to provide Resident 1 with incontinence care assistance. The allegation was unsubstantiated after investigation.
Report Facts
Capacity: 68
Census: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation |
| Yolanda Torres | Clinical Director | Met with investigator and provided information during the investigation |
| Jonathan Wheeler | Administrator | Facility administrator named in the report |
| Simon Jacob | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 68
Deficiencies: 0
Jun 25, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2023-05-16 regarding multiple allegations including unexplained injuries to residents, staff conduct, lack of supervision, and unsanitary conditions.
Findings
The investigation found no corroborating evidence to support the allegations. The findings were determined to be unsubstantiated due to lack of necessary details and inability to prove or disprove the claims.
Complaint Details
The complaint involved allegations of residents sustaining unexplained injuries, inimical staff conduct, lack of supervision resulting in a resident left on the floor for an extended time, staff yelling at residents, failure to follow physician's special diet orders, and unsanitary facility conditions. The findings were unsubstantiated.
Report Facts
Facility capacity: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Teutschel | Evaluator | Conducted the complaint investigation |
| Yolanda Torres | Clinical Director | Interviewed during investigation |
| Jonathan Wheeler | Administrator | New to the facility and involved in investigation |
Inspection Report
Complaint Investigation
Capacity: 68
Deficiencies: 0
Jun 25, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-06-14 regarding staff not meeting residents' hygiene needs, inappropriate interactions, and rough handling of residents.
Findings
The investigation was unable to prove or disprove the allegations due to lack of supporting interviews, and the findings were determined to be unsubstantiated.
Complaint Details
The complaint was unsubstantiated as the Department could not verify the allegations due to insufficient evidence and no additional interviews.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Teutschel | LPM II RA / Licensing Program Analyst | Conducted the telephone conference and investigation. |
| Yolanda Torres | Clinical Director | Met with during investigation; new to the facility. |
| Jonathan Wheeler | Administrator | New to the facility; mentioned in investigation findings. |
Inspection Report
Complaint Investigation
Capacity: 68
Deficiencies: 0
Jun 25, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2022-11-21 regarding allegations that the facility did not ensure a client was treated with dignity.
Findings
The investigation found that two residents who had previously shared a room had an altercation involving a mop retrieved from the trash, resulting in one resident slapping the other. No staff negligence was determined, and the allegation was unsubstantiated.
Complaint Details
The complaint was unsubstantiated after investigation. The Department was unable to prove or disprove the allegation that the facility did not ensure a client was treated with dignity.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Teutschel | Evaluator | Conducted the complaint investigation and telephone conference. |
| Yolanda Torres | Clinical Director | Participated in telephone conference and investigation. |
| Jonathan Wheeler | Administrator | Mentioned as new to the facility and involved in investigation. |
Inspection Report
Complaint Investigation
Capacity: 68
Deficiencies: 0
Jun 25, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation of insufficient staffing to meet residents' needs at Lo-Har Senior Living Facility.
Findings
The investigation included a telephone conference with the Clinical Director and review of available details. The Department was unable to prove or disprove the allegation, and the findings were determined to be unsubstantiated.
Complaint Details
The complaint alleged insufficient staffing to meet residents' needs. The findings were unsubstantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Teutschel | Evaluator | Conducted the complaint investigation and telephone conference. |
| Yolanda Torres | Clinical Director | Participated in telephone conference and is new to the facility. |
| Jonathan Wheeler | Administrator | New to the facility, mentioned in investigation findings. |
Inspection Report
Complaint Investigation
Capacity: 68
Deficiencies: 0
Jun 25, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2022-02-18 regarding allegations that facility staff were not meeting resident needs, physical plant violations, and personal rights violations.
Findings
The investigation was unable to prove or disprove the allegations and the findings were determined to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated after review and telephone conference with Clinical Director Yolanda Torres and Administrator Jonathan Wheeler, both new to the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Teutschel | Evaluator | Conducted the complaint investigation and telephone conference |
| Yolanda Torres | Clinical Director | Met during investigation and involved in telephone conference |
| Jonathan Wheeler | Administrator | New to the facility and involved in telephone conference |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 68
Deficiencies: 0
Jun 16, 2025
Visit Reason
An unannounced complaint investigation was conducted following allegations that staff did not seek medical attention for a resident, did not ensure a resident was fed, did not provide residents with water, and did not ensure the facility was free of malodors.
Findings
The investigation found that the allegations were unsubstantiated based on interviews, record reviews, and observations. The resident with gastrointestinal issues had ongoing medical care, the resident who refused meals had access to protein shakes, water was available throughout the facility, and no malodors were detected in bedding or resident rooms.
Complaint Details
The complaint was received on 2025-04-02 and involved allegations regarding medical attention, feeding, hydration, and facility cleanliness. The allegations were found to be unsubstantiated after investigation.
Report Facts
Capacity: 68
Census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation |
| Jonathan Wheeler | Administrator / Executive Director | Facility representative involved in exit interview |
| Yolanda Torres | Clinical Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 68
Deficiencies: 0
Jun 16, 2025
Visit Reason
An unannounced complaint investigation was conducted following allegations that facility staff did not meet a resident's dietary needs, did not provide laundry service, and did not provide housekeeping service.
Findings
The investigation found that the resident received their special diet but often refused the food and preferred fast food. The resident did not allow staff to provide laundry or housekeeping services, preferring to manage these independently. Based on interviews and record reviews, the allegations were unsubstantiated.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to meet dietary needs, laundry service, and housekeeping service for Resident 1. Evidence showed the resident refused food and did not permit staff to enter the room for laundry or housekeeping.
Report Facts
Facility Capacity: 68
Census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation |
| Jonathan Wheeler | Administrator / Executive Director | Facility administrator present during investigation and exit interview |
| Yolanda Torres | Clinical Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 68
Deficiencies: 0
May 29, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of physical abuse to a resident by facility staff resulting in serious bodily injuries.
Findings
The investigation found insufficient evidence to substantiate the allegation of physical abuse by staff causing serious bodily injuries. The resident had a history of aggressive behavior and injuries were likely caused by an accidental fall during an altercation with staff. The resident was also a suspect in an arson incident at the facility.
Complaint Details
The complaint alleged physical abuse to Resident 1 by facility staff resulting in serious bodily injuries. The allegation was unsubstantiated after investigation, which included interviews, medical records review, and observation of resident behavior and incidents.
Report Facts
Facility capacity: 68
Census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan Wheeler | Executive Director | Met with during investigation and exit interview |
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation |
| Hannah Rodgers | Licensing Program Analyst | Assisted in conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 68
Deficiencies: 2
May 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 08/02/2022 regarding neglect resulting in a Stage 4 pressure injury and failure to meet a resident's incontinence care needs, as well as allegations that the licensee did not seek medical care for a resident and retained a resident with a prohibited health condition without an exception.
Findings
The investigation substantiated neglect resulting in a Stage 4 pressure injury and failure to meet incontinence care needs for Resident 1, posing an immediate safety risk. A civil penalty of $500 was charged. Another complaint regarding failure to seek medical care and retaining a resident with a prohibited condition was unsubstantiated.
Complaint Details
The complaint investigation was substantiated for neglect causing a Stage 4 pressure injury and failure to meet incontinence care needs for Resident 1. The allegations that the licensee did not seek medical care and retained a resident with a prohibited health condition were unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to protect resident from neglect resulting in a Stage 4 pressure injury. | Type A |
| Failure to provide resident with a managed incontinence program. | Type B |
Report Facts
Civil Penalty: 500
Capacity: 68
Census: 67
Plan of Correction Due Date: 1
Plan of Correction Due Date: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan Wheeler | Executive Director | Met with during investigation and exit interview. |
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation. |
| Hannah Rodgers | Licensing Program Analyst | Assisted in conducting the complaint investigation. |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 68
Deficiencies: 0
May 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of neglect/lack of supervision resulting in serious bodily injury to a resident.
Findings
The investigation found that the resident had a pre-existing fractured leg prior to admission and was receiving ongoing medical care. Staff interviews and records showed the facility provided appropriate care and supervision. The complaint was unsubstantiated as the evidence did not meet the standard to prove neglect or lack of supervision resulting in serious bodily injury.
Complaint Details
Complaint alleged neglect/lack of supervision resulting in serious bodily injury to Resident 1. The complaint was unsubstantiated based on review of records and interviews.
Report Facts
Facility capacity: 68
Census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan Wheeler | Executive Director | Met with during investigation and exit interview |
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation |
| Hannah Rodgers | Licensing Program Analyst | Conducted the complaint investigation |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Mar 21, 2025
Visit Reason
An unannounced complaint investigation was conducted following an allegation that staff neglect and/or lack of supervision resulted in a resident-on-resident altercation with injury on December 23, 2024.
Findings
The investigation found that on December 23 and 24, 2024, two residents had physical altercations resulting in injuries to one resident. Staff intervened, provided first aid, and contacted emergency personnel. Additional supervision and room separation measures were implemented. The preponderance of evidence did not support the allegation of staff neglect or lack of supervision.
Complaint Details
The complaint alleged neglect and/or lack of supervision resulting in a resident-on-resident altercation with injury. The investigation was unsubstantiated based on record reviews and interviews. Both residents received medical care and adjustments were made to supervision and medication.
Report Facts
Facility capacity: 68
Census: 68
Complaint received date: Dec 24, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jonathan Wheeler | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 66
Capacity: 68
Deficiencies: 0
Jan 2, 2025
Visit Reason
An unannounced Case Management visit was conducted to follow-up on an incident report regarding missing prescribed as-needed medication for a resident.
Findings
The investigation found that the resident did not miss any medication doses despite the missing medication. No deficiencies were cited during the visit.
Complaint Details
The visit was triggered by an incident report received on 2024-12-18 about missing medication. Interviews and records confirmed the resident had sufficient medication and no doses were missed.
Report Facts
Facility capacity: 68
Resident census: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan Wheeler | Executive Director | Met during inspection and exit interview |
| Iby Strong | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Jenna Purnell | Wellness Coordinator | Interviewed regarding the missing medication incident |
Inspection Report
Complaint Investigation
Capacity: 68
Deficiencies: 0
Nov 20, 2024
Visit Reason
An unannounced Case Management visit was conducted to follow up on an incident report received regarding a resident eloping from the facility on 10/29/2024.
Findings
During the visit, a health and safety check was conducted and consultation provided. No deficiencies were cited during the visit.
Complaint Details
The visit was triggered by an incident report of Resident #1 eloping from the facility on 10/29/2024. The resident was found by a responsible party and the licensee followed the absentee notification plan as necessary.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Jenna Purnell | Wellness Coordinator | Met with Licensing Program Analyst during the visit and exit interview. |
| Yolanda Torres | Clinical Director | Met with Licensing Program Analyst during the visit and exit interview. |
Inspection Report
Annual Inspection
Census: 64
Capacity: 68
Deficiencies: 1
Oct 25, 2024
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing regulations for the facility.
Findings
The facility was generally compliant with regulations, with pathways clear, proper furnishings, and adequate safety equipment. However, one shower valve was not working and multiple sinks were not draining properly, resulting in one cited deficiency.
Deficiencies (1)
| Description |
|---|
| Water supplies and plumbing fixtures were not maintained in operating condition, including one shower valve not working and multiple sinks not draining, affecting all 64 residents. |
Report Facts
Residents in care affected: 64
Deficiency count: 1
Plan of Correction Due Date: Nov 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan Wheeler | Executive Director | Met with Licensing Program Analysts during inspection |
| Iby Strong | Licensing Program Analyst | Conducted the inspection and signed the report |
| Simon Jacob | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 68
Deficiencies: 1
Oct 3, 2024
Visit Reason
The visit was an unannounced Case Management follow-up on an incident reported to Community Care Licensing regarding a resident who went absent without official leave (AWOL) from the facility.
Findings
The licensee failed to be aware of the resident's whereabouts, which posed a potential safety risk. A deficiency was cited for not meeting the basic service requirement to know the resident's general whereabouts.
Complaint Details
The visit was triggered by a complaint regarding Resident #1 leaving the locked memory care unit without staff recognition or prevention, resulting in the resident being found away from the facility.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to be aware of the resident's general whereabouts, although the resident may travel independently in the community, posing a potential safety risk. | Type B |
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Oct 10, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Pepin | Business Office Manager | Met during inspection and involved in discussion of incident |
| Yolanda Torres | Clinical Director | Met during inspection and involved in discussion of incident |
| Iby Strong | Licensing Program Analyst | Conducted the inspection and authored the report |
| Simon Jacob | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 68
Deficiencies: 0
Oct 3, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that lack of supervision resulted in a resident-on-resident altercation.
Findings
The investigation found no preponderance of evidence to prove the alleged violation occurred; the allegation was unsubstantiated after interviews and record reviews.
Complaint Details
The complaint alleged that Resident 1 hit Resident 2 causing a bruise on Resident 2's face due to lack of supervision. Interviews revealed the incident was isolated, with staff nearby at the time, and no prior history of disagreements or violence between the residents.
Report Facts
Facility capacity: 68
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation |
| Amanda Pepin Laphen | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Yolanda Torres | Clinical Director | Present during investigation and exit interview |
| Simon Jacob | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 68
Deficiencies: 1
Oct 3, 2024
Visit Reason
An unannounced Case Management Visit was conducted to cite a deficiency identified during a separate complaint investigation regarding an incident of resident assault and failure to report.
Findings
The licensee failed to report an assault incident involving Resident 1 and Resident 2 on September 24, 2024, to Community Care Licensing or the Long Term Care Ombudsman, which posed a safety risk to persons in care.
Complaint Details
The visit was complaint-related, citing failure to report an assault incident involving Resident 1 on September 24, 2024. The deficiency was substantiated based on records and interviews.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult to the local ombudsman, licensing agency, and local law enforcement within 24 hours as required by Welfare and Institutions Code Section 15630(b)(1). | Type B |
Report Facts
Census: 64
Total Capacity: 68
Deficiency Type Count: 1
Plan of Correction Due Date: Oct 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the unannounced Case Management Visit and cited the deficiency |
| Amanda Pepin | Business Office Manager | Met with Licensing Program Analyst during inspection and exit interview |
| Yolanda Torres | Clinical Director | Met with Licensing Program Analyst during inspection and exit interview |
Inspection Report
Plan of Correction
Census: 65
Capacity: 68
Deficiencies: 1
May 22, 2024
Visit Reason
The visit was conducted as a plan of correction visit to address ongoing civil penalties related to a duplicate deficiency issued for a violation of California Code of Regulations Section 87411(c)(1).
Findings
The licensee was issued a duplicate deficiency on 5/17/2024 for a violation originally cited on 11/3/2023. Proof of correction was provided by the Executive Director on 5/21/2024. A civil penalty of $100 per day was assessed from 5/18/2024 to 5/21/2024.
Deficiencies (1)
| Description |
|---|
| Violation of California Code of Regulations Section 87411(c)(1) resulting in a duplicate deficiency. |
Report Facts
Civil penalty amount: 400
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Pepin-Laphen | Business Office Manager | Met with during the plan of correction visit and participated in the exit interview. |
| Iby Strong | Licensing Program Analyst | Conducted the plan of correction visit. |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 68
Deficiencies: 0
May 17, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation received on 2024-04-30 that a resident was not allowed to contact emergency personnel.
Findings
The investigation found no preponderance of evidence to support the allegation that the resident was restricted from contacting emergency personnel. Staff interviews and record reviews indicated the resident continuously contacts emergency personnel and is not limited from using their cell phone. The allegation was unsubstantiated.
Complaint Details
The complaint alleged that staff did not allow a resident to contact emergency personnel. The allegation was investigated and found to be unsubstantiated.
Report Facts
Capacity: 68
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jared Green | Executive Director | Facility representative interviewed during the investigation |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 68
Deficiencies: 1
May 17, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2024-04-29 alleging staff did not respond to communications from a resident's representative in a timely and appropriate manner, and other related allegations regarding resident assistance and supervision.
Findings
The investigation substantiated that staff failed to respond promptly and appropriately to communications from a resident's representative, posing a potential personal rights risk. Another allegation that staff did not assist a resident with obtaining community services and did not allow the resident to leave unassisted was unsubstantiated based on interviews and record reviews.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not respond to communications from the resident's representative in a timely and appropriate manner. The allegation that staff did not assist the resident with obtaining services in the community and did not allow the resident to leave unassisted was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have communications to the licensee from resident representatives answered promptly and appropriately, violating CCR 87468.1(a)(9). | Type B |
Report Facts
Capacity: 68
Census: 65
Deficiency Type B: 1
Plan of Correction Due Date: May 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jared Green | Executive Director | Facility representative met during investigation and exit interview |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 68
Deficiencies: 1
May 17, 2024
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2024-04-09 alleging that the licensee did not ensure staff were trained, did not reassess residents, did not provide a safe environment, did not prevent residents from smoking in non-smoking areas, did not maintain the facility in good repair, and did not maintain a comfortable temperature for residents.
Findings
The investigation substantiated that the licensee failed to provide current first aid training to 13 of 16 staff, posing a potential health and safety risk to 56 residents. Other allegations regarding reassessment of residents, safe environment, smoking prevention, facility maintenance, and temperature control were unsubstantiated based on record reviews, interviews, and facility inspection.
Complaint Details
The complaint was substantiated regarding staff training deficiencies. Other allegations including failure to reassess residents, unsafe environment, smoking in non-smoking areas, poor facility maintenance, and uncomfortable temperatures were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not provide first aid training to 13 of 16 staff, which poses a potential health and safety risk to 56 persons in care. | Type B |
Report Facts
Staff without current first aid training: 13
Staff with CPR training: 16
Residents in care: 56
Facility capacity: 68
Plan of Correction due date: May 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jared Green | Executive Director | Met during investigation and exit interview |
| Iby Strong | Licensing Program Analyst | Conducted complaint investigation |
| Simon Jacob | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Plan of Correction
Census: 65
Capacity: 68
Deficiencies: 0
May 6, 2024
Visit Reason
The visit was conducted to verify if the deficiencies issued on 2024-03-29 had been corrected, as the licensee had not submitted proof of correction by the original due date of 2024-04-29.
Findings
During the visit, it was found that the previous Wellness Director had not communicated the deficiencies report or the plan of correction due date to the current Administrator and Interim Wellness Director. The previous Wellness Director had left the facility on 2024-04-15. An extension for the plan of correction due date was granted until 2024-05-31.
Report Facts
Capacity: 68
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jared Green | Administrator | Met during inspection and involved in findings discussion |
| Jenna Purnell | Interim Wellness Director | Met during inspection and involved in findings discussion |
| Rebecca Ruiz | Licensing Program Analyst | Conducted the plan of correction visit |
Inspection Report
Census: 65
Capacity: 68
Deficiencies: 0
Apr 19, 2024
Visit Reason
An unannounced Case Management visit was conducted to follow-up on an incident reported to Community Care Licensing involving a resident who went absent without official leave.
Findings
The Licensing Program Analyst conducted a health and safety check and consultation, observed an auditory alarm installed in the memory care cottage, and cited no deficiencies during the visit.
Report Facts
Incident report date: Apr 15, 2024
Incident date: Apr 13, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jared Green | Executive Director | Met with Licensing Program Analyst during the visit |
| Anastasia Hanna | Medication Technician | Participated in exit interview and was provided appeal rights |
Inspection Report
Census: 64
Capacity: 68
Deficiencies: 0
Mar 29, 2024
Visit Reason
An unannounced case management visit was conducted to deliver an amended LIC9099 complaint report and obtain the signature of the Wellness Director.
Findings
The Licensing Program Analyst delivered the amended complaint report dated 1/27/2023 and obtained the Wellness Director's signature confirming receipt of the report and licensee appeal rights.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Ruiz | Licensing Program Analyst | Conducted the unannounced case management visit and delivered the amended complaint report. |
| Rosa Barajas | Wellness Director | Received the amended complaint report and signed to confirm receipt. |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 68
Deficiencies: 6
Mar 29, 2024
Visit Reason
An unannounced complaint investigation visit was conducted due to allegations including inadequate staffing, facility cleanliness issues, unmet resident care needs, and failure to follow physician's orders.
Findings
The investigation substantiated multiple deficiencies including inadequate staffing, poor facility cleanliness, failure to meet residents' incontinence and hygiene needs, and failure to follow physician's orders, resulting in a civil penalty. One allegation regarding neglect of medical care resulting in hospitalization was unsubstantiated.
Complaint Details
The complaint investigation was triggered by allegations of inadequate staffing, poor facility cleanliness, unmet resident care needs including incontinence and hygiene, failure to follow physician's orders, and neglect of medical care resulting in hospitalization. The neglect of medical care allegation was unsubstantiated, while the others were substantiated.
Severity Breakdown
Type A: 1
Type B: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Licensee did not ensure that Resident 1’s physician’s order for assistance with feeding and oxygen use was followed, resulting in hospitalization. | Type A |
| Facility personnel were not sufficient in numbers and competent to meet resident needs. | Type B |
| Facility was not kept clean, cluttered and dirty on multiple occasions. | Type B |
| Soiled incontinence briefs were not emptied frequently enough to prevent odors. | Type B |
| Incontinent residents were not assisted to remain clean and dry. | Type B |
| Residents were not assisted with bathing services as needed. | Type B |
Report Facts
Civil penalty amount: 500
Resident census: 64
Facility capacity: 68
Staff scheduled per 8-hour shift: 4
Plan of Correction due date: Apr 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Rosa Barajas | Wellness Director | Facility staff member met during inspection and named in findings. |
| Kandy Ducharme-Franklin | Administrator | Facility administrator named in report header. |
| Amanda Pepin | Business Office Manager | Met by Licensing Program Analyst during visit. |
| Staff 1 | Reported Resident 1's change in condition to Wellness Director. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 68
Deficiencies: 0
Mar 26, 2024
Visit Reason
An unannounced complaint investigation was conducted following allegations that staff falsified medication records and did not issue medication as prescribed to Resident 1.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews and record reviews confirmed that Resident 1 did not decline medication and medication administration records were accurate with appropriate coding for medication not administered during the resident's absence.
Complaint Details
The complaint alleged staff falsified medication records and failed to issue medication as prescribed to Resident 1. The allegations were found to be unsubstantiated after review of records and interviews.
Report Facts
Capacity: 68
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Amanda Pepin | Business Office Manager | Met with Licensing Program Analyst during the investigation |
| Kandy Ducharme-Franklin | Administrator | Facility administrator named in the report |
Inspection Report
Census: 65
Capacity: 68
Deficiencies: 0
Mar 11, 2024
Visit Reason
An unannounced Case Management visit was conducted to follow-up on an incident reported to Community Care Licensing regarding a resident who went absent without official leave (AWOL) from the facility.
Findings
During the visit, a health and safety check of the residents was conducted and consultation was provided. No deficiencies were cited during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jared Green | Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 68
Deficiencies: 0
Mar 11, 2024
Visit Reason
An unannounced complaint investigation was conducted following a complaint alleging that Resident 1 was unlawfully evicted and not allowed to return to the facility after a hospital stay.
Findings
The investigation found no preponderance of evidence to prove the alleged violation occurred; the allegation of unlawful eviction was unsubstantiated. Resident 1 did return to the facility on March 7, 2024, and communication with the hospital about the resident's stability was confirmed.
Complaint Details
Complaint alleged Resident 1 was not allowed to return to the facility after hospital stay and was issued a 30-day eviction notice. Investigation found the allegation unsubstantiated.
Report Facts
Capacity: 68
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation |
| Jared Green | Executive Director | Interviewed during investigation and exit interview |
| Kandy Ducharme-Franklin | Administrator | Interviewed regarding resident's hospital communication |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 68
Deficiencies: 1
Feb 14, 2024
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2024-02-07 alleging that residents were not being assisted with activities of daily living.
Findings
The investigation found that multiple residents, including Resident 1 diagnosed with Parkinson's disease, were not receiving required assistance with dressing and grooming. Observations and interviews confirmed that residents waited for caregiver assistance that was not provided, supporting the substantiated complaint.
Complaint Details
The complaint was substantiated. Resident 1 was not assisted with daily dressing as required, and residents reported being denied assistance multiple times. Observations confirmed lack of caregiver availability and grooming assistance over multiple days.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide basic services including personal assistance with activities of daily living such as dressing, eating, and bathing to residents as required by pre-admission appraisal. | Type B |
Report Facts
Residents affected: 3
Capacity: 68
Census: 62
Plan of Correction Due Date: Feb 28, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
| Jared Green | Executive Director | Facility representative interviewed during investigation and exit interview |
| Kandy Ducharme-Franklin | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 68
Deficiencies: 0
Jan 23, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not follow a resident's care plan.
Findings
The investigation found no evidence to support the allegation that staff failed to follow the resident's care plan. Interviews and record reviews indicated the resident did not have a Do Not Resuscitate (DNR) order documented, and staff had no knowledge of such documentation. The allegation was unsubstantiated.
Complaint Details
The complaint alleged that staff did not follow a resident's care plan. The investigation was unsubstantiated due to lack of evidence.
Report Facts
Capacity: 68
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Jenna Purnell | Wellness Director | Interviewed during the investigation and present at exit interview |
| Kandy Ducharme-Franklin | Administrator | Facility administrator named in the report |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 68
Deficiencies: 0
Jan 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of lack of supervision resulting in serious bodily injury and insufficient staffing to meet residents' needs.
Findings
The investigation found that the resident's fall was not due to inadequate staffing or lack of supervision. The allegations were unsubstantiated based on observations, interviews, and records review.
Complaint Details
The complaint alleged lack of supervision resulting in serious bodily injury to Resident 1 and insufficient staffing. The investigation revealed Resident 1 fell while attempting to walk, resulting in a hip fracture. Staff were present and responded promptly. Resident 1 is prone to falls due to medical condition and behavior. Staffing was below pre-pandemic levels but sufficient to meet residents' needs. The findings were unsubstantiated.
Report Facts
Capacity: 68
Census: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Becky Kennedy | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Karriem Jones | MedTech | Met with during the investigation and received the report |
| Icela Estrada | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 68
Deficiencies: 0
Jan 2, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation received on 12/07/2023 that staff did not assist a resident with feeding.
Findings
The investigation found no preponderance of evidence to substantiate the allegation that staff failed to assist the resident with feeding. Interviews and record reviews indicated the resident requested and received assistance from one staff member and generally did not request help from others.
Complaint Details
The complaint alleging staff did not assist Resident 1 with feeding was unsubstantiated based on interviews with staff, the resident, and an outside source, as well as review of resident records and care plans.
Report Facts
Capacity: 68
Census: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jared Green | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 64
Capacity: 68
Deficiencies: 0
Dec 12, 2023
Visit Reason
The visit was a Case Management - Incident visit conducted following notification of a fire that occurred in Building B, room 8 of the facility on 12/11/2023.
Findings
The Licensing Program Analyst conducted a health and safety check on residents and the fire-affected room, finding the room clean with damaged furnishings replaced. No deficiencies were cited or observed during the visit.
Report Facts
Number of buildings on property: 6
Residents evacuated: 20
Fire alarm time: 845
Fire all clear time: 130
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenna Purnell | Wellness Director | Met with Licensing Program Analyst during the visit. |
| Iby Strong | Licensing Program Analyst | Conducted the Case Management Visit. |
| Simon Jacob | Licensing Program Manager | Named in report header. |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 68
Deficiencies: 0
Dec 12, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2023-11-14 regarding staff neglect, inappropriate living arrangements, failure to prevent harm between residents, and improper incident reporting.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Resident 1's bedsore was properly cared for, Resident 2's living arrangement was appropriate and preferred, staff supervision of Resident 3 and Resident 4 was adequate despite an incident, and the responsible party was contacted about the incident involving Resident 4.
Complaint Details
The complaint alleged staff neglect causing a bedsore, inappropriate living arrangements, failure to prevent harm between residents, and failure to properly report an incident. The investigation concluded the allegations were unsubstantiated based on interviews, record reviews, and observations.
Report Facts
Facility capacity: 68
Resident census: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jenna Purnell | Wellness Director | Met with Licensing Program Analyst during the investigation |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 68
Deficiencies: 1
Nov 20, 2023
Visit Reason
An unannounced complaint investigation was conducted following allegations that medication was not issued as prescribed at the facility.
Findings
The investigation substantiated that medication was not issued as prescribed, with medication found on the floors of resident rooms and delays in receiving medication orders from the pharmacy. Five of 65 persons in care were affected, posing a potential health risk.
Complaint Details
The complaint was substantiated. Medication was not issued as prescribed, with evidence including medication found on the floor and delayed medication orders. The investigation was conducted by Licensing Program Analyst Iby Strong.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not issue medication as prescribed in five of 65 persons in care, violating CCR 87465(c)(2). | Type B |
Report Facts
Persons in care affected: 5
Total persons in care: 65
Facility census: 63
Facility capacity: 68
Plan of Correction due date: Due date stated as December 27, 2023.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Jared Green | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview. |
| Simon Jacob | Licensing Program Manager | Named in the report as Licensing Program Manager overseeing the investigation. |
Inspection Report
Annual Inspection
Census: 65
Capacity: 68
Deficiencies: 2
Nov 3, 2023
Visit Reason
An unannounced required one-year inspection was conducted to ensure substantial compliance with Title 22 regulations at the Lo-Har Senior Living Facility.
Findings
The facility was generally compliant with regulations including safety equipment, food storage, and medication management. However, deficiencies were cited related to staff first aid training and safety in showers, with plans of correction developed.
Deficiencies (2)
| Description |
|---|
| Based on record review, the licensee did not comply with personnel requirements for first aid training in 3 of 5 staff, posing potential health and safety risks. |
| Based on observations, the licensee did not comply with safety requirements in 2 of 6 showers, posing potential health and safety risks. |
Report Facts
Deficient staff count: 3
Deficient showers count: 2
Capacity: 68
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the inspection and authored the report |
| Denise Powell | Licensing Program Manager | Supervisor overseeing the inspection |
| Jared Green | Executive Director | Facility representative involved in the inspection and plan of correction |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 68
Deficiencies: 0
Nov 2, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not provide resident access to the facility phone.
Findings
The investigation found that Resident 1 had access to a telephone in their cottage and staff regularly assisted with telephone use. There was no preponderance of evidence to prove the alleged violation occurred, and the complaint was unsubstantiated.
Complaint Details
The complaint alleged that Resident 1 was not allowed to use the facility telephone to contact outside sources. The allegation was found to be unsubstantiated based on interviews, observations, and record reviews.
Report Facts
Capacity: 68
Census: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation |
| Jenna Purnell | Wellness Director | Interviewed during the investigation |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 63
Capacity: 68
Deficiencies: 0
Oct 30, 2023
Visit Reason
An unannounced Case Management Visit was conducted to observe the physical plant and review the facility's secured perimeter request and fire clearance approval related to the memory care buildings.
Findings
The Licensing Program Analyst observed no immediate health or safety issues and cited no deficiencies. The facility's secured perimeter was approved by the local fire authority, and staff interviews confirmed appropriate resident supervision practices. The application process for the secured perimeter is complete pending final management review.
Report Facts
Capacity: 68
Census: 63
Memory care buildings: 2
Disaster drills: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management Visit and authored the report |
| Jared Green | Administrator | Facility administrator met with Licensing Program Analyst and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 68
Deficiencies: 1
Oct 25, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2023-09-14 alleging staff failed to provide activities for residents, did not meet residents' needs, did not follow admission agreements, and changed a resident's medical appointment without permission.
Findings
The investigation substantiated that staff failed to provide planned activities to all 65 residents, posing a potential health risk. However, allegations that the licensee did not meet residents' needs, did not follow admission agreements, and changed a resident's medical appointment without permission were unsubstantiated.
Complaint Details
The complaint was substantiated regarding failure to provide activities for residents. Other allegations about unmet resident needs, admission agreement violations, and unauthorized changes to medical appointments were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide planned activities to residents, which posed a potential health risk. | Type B |
Report Facts
Capacity: 68
Census: 65
Deficiencies cited: 1
Plan of Correction Due Date: Nov 7, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
| Jared Green | Executive Director | Facility representative interviewed during the investigation |
| Kandy Ducharme-Franklin | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 68
Deficiencies: 0
Oct 25, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following an allegation received on 2023-10-05 that facility staff financially abused a resident.
Findings
The investigation found no evidence to support the allegation of financial abuse. Resident records, facility financial documents, and interviews did not reveal any unauthorized withdrawals or suspicious activity linked to the facility staff. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that facility staff financially abused Resident 1. The allegation was unsubstantiated after review of resident and facility records and interviews with the resident and an outside source.
Report Facts
Facility capacity: 68
Resident census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jared Green | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Simon Jacob | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 68
Deficiencies: 0
Sep 27, 2023
Visit Reason
An unannounced complaint investigation was conducted following allegations of neglect resulting in a resident suffering a medical emergency, failure to maintain a resident's medical records, and staff not providing a resident with a bed.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Resident 1 was assessed multiple times prior to a medical emergency and no neglect was indicated. Resident 2's medical records were maintained accurately, and the resident chose to sleep in a wheelchair rather than the assigned bed.
Complaint Details
The complaint was unsubstantiated. Allegations included neglect causing a medical emergency for Resident 1, failure to maintain Resident 2's medical records, and failure to provide Resident 2 with a bed. Interviews, record reviews, and observations did not support these allegations.
Report Facts
Facility capacity: 68
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation |
| Jenna Purnell | Wellness Director | Interviewed during investigation |
| Jared Green | Executive Director | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 68
Deficiencies: 0
Sep 25, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2023-06-14 regarding staff hitting a resident and failure to safeguard residents' belongings.
Findings
The investigation found no evidence to substantiate the allegations of staff hitting residents or failing to safeguard residents' belongings. Interviews with residents, staff, and outside sources, as well as record reviews, supported that the allegations were unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on evidence including interviews with residents and staff, record reviews, and observations. Allegations included staff hitting a resident and failure to safeguard residents' belongings.
Report Facts
Capacity: 68
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Jenna Purnell | Wellness Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Kandy Ducharme-Franklin | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 68
Deficiencies: 0
Sep 20, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff were physically rough when assisting a resident.
Findings
The investigation included interviews and record reviews which revealed inconsistent statements and no preponderance of evidence to support the allegation. The complaint was deemed unsubstantiated.
Complaint Details
The allegation was that staff were physically rough with Resident #1 on 08/09/23 causing left side hip pain. Medical assessments found no injuries or trauma. Resident #1 was wheelchair bound and had a history of fabricating stories. Staff and resident interviews confirmed facility staff were not physically rough.
Report Facts
Facility capacity: 68
Resident census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
| Jenna Purnell | Wellness Director | Met with Licensing Program Analyst during investigation and received report |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 63
Capacity: 68
Deficiencies: 1
Sep 13, 2023
Visit Reason
An unannounced Case Management visit was conducted to review records, including disaster drill records, evacuation routes, and physician reports for residents in memory care areas.
Findings
One deficiency was cited for failure to possess an LIC602 Physician’s Report or equivalent Medical Assessment for one resident prior to acceptance, posing a potential health, safety, and personal rights risk. A Plan of Correction was jointly developed with the licensee.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not possess an LIC602 Physician’s Report or equivalent Medical Assessment for Resident #1 prior to acceptance. | Type B |
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Oct 13, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management visit and cited the deficiency |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the inspection |
| Jared Green | Administrator | Facility administrator interviewed during the visit |
| Jenna Purnell | Wellness Coordinator | Facility wellness coordinator interviewed during the visit |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 68
Deficiencies: 0
Sep 8, 2023
Visit Reason
The inspection visit was conducted to investigate a complaint alleging that the facility is in disrepair, specifically concerning a water leak in the ceiling affecting residents and the building.
Findings
The investigation found an active ceiling leak caused by an old HVAC system, with management having contracts in place to begin repairs. The affected area was closed off with caution tape and no health or safety issues were present. The allegation was unsubstantiated due to lack of evidence of violation.
Complaint Details
The complaint alleged the facility is in disrepair due to a water leak in the ceiling. The allegation was unsubstantiated after inspection, interviews, and record review.
Report Facts
Capacity: 68
Census: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Jared Green | Executive Director | Met with during inspection and interview |
Inspection Report
Complaint Investigation
Capacity: 68
Deficiencies: 0
Aug 30, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not afford a resident privacy during phone calls.
Findings
The investigation included interviews, facility inspection, and record review. It was found that residents are accorded privacy during phone use, with phones located in common areas and a protocol allowing private phone calls upon request. The allegation was unsubstantiated due to lack of evidence.
Complaint Details
The complaint alleged that Resident 1 was not afforded privacy during phone calls. The allegation was unsubstantiated after investigation.
Report Facts
Facility capacity: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation |
| Jenna Purnell | Wellness Director | Met with Licensing Program Analyst during investigation |
| Jared Green | Executive Director | Participated in exit interview |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 68
Deficiencies: 2
Aug 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 07/25/2023 alleging that staff handled a resident in a rough manner and spoke inappropriately to the resident.
Findings
The investigation substantiated the allegations that Staff 1 grabbed Resident 1 by the wrists in a rough manner and used profanity against the resident. The licensee failed to protect the resident's personal rights, posing an immediate safety risk and a potential personal rights risk to persons in care.
Complaint Details
The complaint was substantiated. Allegations included staff handling a resident in a rough manner and speaking inappropriately to the resident. Evidence included witness statements, resident records, and interviews confirming the incident on July 11, 2023.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to protect resident's personal right to be free from abuse in 1 of 57 persons in care (Resident 1), posing an immediate safety risk. | Type A |
| Failure to accord resident dignity in their personal relationship with staff in 1 of 57 persons in care (Resident 1), posing a potential personal rights risk. | Type B |
Report Facts
Capacity: 68
Census: 62
Persons in care referenced: 57
Deficiency Type A due date: Aug 31, 2023
Deficiency Type B due date: Sep 13, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
| Jenna Purnell | Wellness Director | Met with during investigation and exit interview |
| Jared Green | Executive Director | Met with during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 68
Deficiencies: 0
Aug 30, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint alleging physical abuse of a resident at the facility.
Findings
The investigation found no preponderance of evidence to substantiate the allegation of physical abuse. Interviews and record reviews did not corroborate the complaint, and the allegation was determined to be unsubstantiated.
Complaint Details
Complaint alleged that Resident 1 was physically abused by an unknown source on August 11, 2023. The allegation was unsubstantiated after investigation.
Report Facts
Capacity: 68
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation |
| Jenna Purnell | Wellness Director | Met with Licensing Program Analyst during the investigation |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
| Jared Green | Executive Director | Participated in exit interview |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 68
Deficiencies: 0
Aug 29, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations including illegal eviction, uncleared staff at the facility, facility toilets in disrepair, and failure to conduct emergency drills as required.
Findings
The investigation found no evidence to substantiate the allegations. Interviews and observations confirmed no illegal eviction occurred, all staff were properly cleared, toilets were maintained and functional, and monthly emergency drills were conducted with documentation provided.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included illegal eviction, uncleared staff, facility toilets in disrepair, and failure to conduct emergency drills. Interviews and documentation did not support these claims.
Report Facts
Capacity: 68
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany Holmes | Licensing Program Analyst | Conducted the complaint investigation visit |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Jenna Purnell | Wellness Coordinator | Met with the Licensing Program Analyst during the visit and participated in interviews |
| Kandy Ducharme-Franklin | Administrator | Facility administrator mentioned in the investigation narrative |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 68
Deficiencies: 1
Jul 26, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 05/11/2023 alleging that the licensee did not report changes in medical condition for two residents and neglect resulting in injuries and restraint.
Findings
The investigation substantiated that the licensee failed to report changes in mental and physical health conditions for two residents, posing a potential health risk. However, allegations of neglect resulting in pressure injuries and multiple injuries to Resident 1 were unsubstantiated, as was the allegation that Resident 1 was restrained by facility staff.
Complaint Details
The complaint was substantiated regarding failure to report changes in condition for two residents (R1 and R2). The allegations of neglect causing pressure injury, multiple injuries, and restraint to Resident 1 were unsubstantiated.
Deficiencies (1)
| Description |
|---|
| Licensee did not report changes such as deterioration of mental ability or physical health condition to the resident's physician as required. |
Report Facts
Capacity: 68
Census: 58
Persons in care with unreported condition changes: 2
Plan of Correction Due Date: Aug 9, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
| Jenna Purnell | Wellness Coordinator | Facility staff member interviewed during investigation and exit interview |
| Kandy Ducharme-Franklin | Administrator | Facility administrator interviewed regarding resident injuries |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 68
Deficiencies: 0
Jul 26, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 05/22/2023 regarding staff taking a resident's personal item without permission, verbally threatening residents, and not treating a resident with dignity and respect.
Findings
The investigation found no preponderance of evidence to support the allegations. Interviews with the resident, other residents, and staff did not corroborate the claims, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff took Resident 1's personal items without permission, verbally threatened Resident 1, and did not treat Resident 1 with dignity and respect. The investigation concluded these allegations were unsubstantiated.
Report Facts
Complaint received date: May 22, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Jenna Purnell | Wellness Coordinator | Facility representative met during the investigation and exit interview |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 68
Deficiencies: 3
Jul 5, 2023
Visit Reason
The visit was conducted in response to an LIC624 Incident Report regarding Resident #1 eloping from the facility without staff supervision on 06/12/2023.
Findings
The investigation found that Resident #1 was not properly observed, contributing to the elopement incident. A perimeter gate was found not fully self-closing and latching, which was repaired after the incident. The facility lacked updated physician's medical assessment for Resident #1 and did not have approval for secured perimeter gates from the State Fire Marshall or CCLD. Deficiencies were cited and a $500 civil penalty was issued.
Complaint Details
The visit was complaint-related, triggered by an incident report of Resident #1 eloping from the facility. The complaint was substantiated based on evidence that the licensee failed to provide needed observation and lacked updated medical assessment documentation.
Severity Breakdown
Type A: 1
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Licensee locked exterior doors and perimeter fence gates without ensuring fire clearance approval, posing an immediate safety risk. | Type A |
| Licensee did not ensure that Resident #1 was regularly observed, posing a potential safety risk. | Type B |
| Licensee did not ensure Resident #1 had an updated medical assessment within the last year, posing a potential health, safety, and personal rights risk. | Type B |
Report Facts
Civil Penalty: 500
Residents involved: 1
Residents in memory care section: 30
Total residents: 55
Total capacity: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit and authored the report. |
| Itzayana Barba | Manager | Interviewed during the inspection regarding the incident and facility operations. |
| Jenna Purnell | Wellness Coordinator | Interviewed during the inspection and participated in the exit interview. |
| Kandy Ducharme-Franklin | Administrator | Facility administrator named in the report header. |
| Lizzette Tellez | Licensing Program Manager | Supervised the licensing evaluation and signed the report. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 68
Deficiencies: 0
Jun 26, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2023-05-12 alleging neglect resulting in injury to Resident 1.
Findings
The investigation included interviews and record reviews, and found no preponderance of evidence to substantiate the allegation of neglect resulting in injury. The complaint was determined to be unsubstantiated.
Complaint Details
Complaint alleged neglect resulting in injury to Resident 1 due to a large bruise observed on the resident's left eye. Investigation revealed no evidence to identify the cause of the bruise and no substantiation of the allegation.
Report Facts
Facility capacity: 68
Census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rhon Hipolito | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 68
Deficiencies: 0
Jun 26, 2023
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that neglect resulted in resident elopement at the facility.
Findings
The investigation found no preponderance of evidence to prove the alleged neglect occurred. The resident had eloped unassisted once on May 31, 2023, but the facility followed established protocols and the allegation was unsubstantiated.
Complaint Details
The complaint alleged neglect resulting in resident elopement. The allegation was unsubstantiated after interviews and record reviews.
Report Facts
Resident elopement incidents: 5
Facility capacity: 68
Census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Rhon Hipolito | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 68
Deficiencies: 0
Jun 26, 2023
Visit Reason
An unannounced complaint investigation was conducted due to allegations that the facility was operating without an administrator and had untreated pests.
Findings
The investigation found that the facility had a new administrator with active certification and was within the required reporting timeframe. No evidence of untreated pests was found, with staff and residents reporting no pest issues and records showing monthly pest treatments. The allegations were unsubstantiated.
Complaint Details
The complaint alleged the facility was without an administrator and did not treat for pests. The investigation concluded these allegations were unsubstantiated based on interviews, inspections, and record reviews.
Report Facts
Capacity: 68
Census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and facility inspection |
| Rhon Hipolito | Administrator | Facility administrator interviewed during the investigation |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 68
Deficiencies: 1
Apr 28, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint alleging that staff did not provide residents clean linens on a weekly basis and that staff disposed of residents' personal property.
Findings
The investigation substantiated that staff did not provide clean linens weekly, posing a potential health and personal rights risk to all 56 residents. Another allegation that staff disposed of a resident's motorized wheelchair was found to be unfounded.
Complaint Details
The complaint investigation was substantiated regarding failure to provide clean linens weekly, meeting the preponderance of evidence standard. The allegation that staff disposed of residents' personal property, specifically a motorized wheelchair, was unfounded.
Deficiencies (1)
| Description |
|---|
| Failure to provide clean linen, including blankets, bedspreads, top and bottom bed sheets, on a weekly basis as required. |
Report Facts
Residents affected: 56
Facility capacity: 68
Census: 56
Plan of Correction due date: May 19, 2023
Residents with soiled linens observed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marisela Garcia-Centeno | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| John Rante | Licensing Program Manager | Oversaw the complaint investigation |
| Kandy Ducharme-Franklin | Administrator | Facility administrator involved in discussions and plan of correction |
| Amy Castillo | Wellness Director | Met with Licensing Program Analyst during investigation |
| Jenna Purnell | Wellness Coordinator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 68
Deficiencies: 0
Apr 13, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations received on 2023-02-21 regarding staff conduct and resident care at Lo-Har Senior Living Facility.
Findings
The investigation included interviews, record reviews, and observations. Allegations included staff not ensuring residents received meals, staff sleeping during working hours, inappropriate speech to residents, forcing residents to shower, forcing food into a resident's mouth, and lack of resident privacy. The investigation found inconsistent statements and insufficient evidence to substantiate the allegations; therefore, all allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations involved staff not ensuring residents received meals, staff sleeping during working hours, inappropriate speech to residents, forcing a resident to shower, forcing food into a resident's mouth, and not ensuring resident privacy. Interviews and observations did not provide a preponderance of evidence to support the allegations.
Report Facts
Facility capacity: 68
Resident census: 56
Complaint receipt date: Feb 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jenna Purnell | Wellness Coordinator | Facility staff member met with during investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 68
Deficiencies: 0
Apr 7, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation received on 12/19/2022 regarding neglect/lack of supervision resulting in injury to a resident.
Findings
The investigation found no preponderance of evidence to prove the alleged neglect or lack of supervision occurred, and the allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged neglect/lack of supervision resulting in injury to Resident 1 who wandered away from the facility on December 17, 2022, resulting in a fall and injury. The resident was treated at a hospital for a skin tear, bruising, and possible infection. Interviews and record reviews did not substantiate the allegation.
Report Facts
Facility capacity: 68
Census: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| John Rante | Licensing Program Manager | Named in report as Licensing Program Manager |
| Kandy Franklin | Administrator | Facility Administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 68
Deficiencies: 1
Apr 7, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted as a Case Management Visit to evaluate deficiencies related to resident care in a locked memory care unit.
Findings
The investigation found that a resident (R1) was residing in a locked memory care unit without a diagnosis of major neurocognitive impairment and without an updated Individual Care Plan addressing the resident's needs in that unit. This posed a potential health, safety, and personal rights risk.
Complaint Details
The complaint investigation revealed that resident R1 was placed in a locked memory care unit without a major neurocognitive impairment diagnosis and lacked an updated Individual Care Plan to meet their needs. The deficiency was substantiated and cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to identify how the facility would meet the resident's needs in the locked memory care unit, posing a potential health, safety, and personal rights risk. | Type B |
Report Facts
Census: 56
Total Capacity: 68
Deficiencies cited: 1
Plan of Correction Due Date: Due date set for 04/21/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kandy Ducharme-Franklin | Administrator | Met with Licensing Program Analyst during the visit and named in relation to the deficiency |
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| John Rante | Licensing Program Manager | Supervisor overseeing the investigation and cited in the report |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 68
Deficiencies: 0
Feb 27, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following allegations that staff did not prevent a resident from wandering away from the facility and did not address a resident's change in medical condition.
Findings
The investigation found that the resident wandered away from the facility on two occasions, but the facility followed all absentee notification procedures and moved the resident to a memory care cottage after the first incident. There was no documented change in the resident's condition prior to the first wandering incident. Based on interviews and record reviews, there was insufficient evidence to substantiate the allegations.
Complaint Details
The complaint was unsubstantiated. Allegations included staff failing to prevent a resident from wandering away on June 11, 2022, and December 17, 2022, and failing to address a change in the resident's condition prior to June 11, 2022. The facility followed procedures during both incidents, and no change in condition was documented prior to the first wandering incident.
Report Facts
Facility capacity: 68
Census: 57
Complaint received date: Jun 13, 2022
Incident dates: Jun 11, 2022
Incident dates: Dec 17, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| John Rante | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Jenna Purnell | Wellness Coordinator | Facility staff member met during the investigation and exit interview |
| Kandy Ducharme-Franklin | Administrator | Facility Administrator interviewed regarding incidents and resident condition |
| Staff 1 | Staff member contacted by telephone after resident was found wandering |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 68
Deficiencies: 0
Dec 21, 2022
Visit Reason
The visit was an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing regarding a resident who went absent without official leave (AWOL).
Findings
During the visit, a health and safety check was conducted and consultation provided. No deficiencies were cited during the visit.
Complaint Details
The complaint involved Resident #1 going AWOL on 12/17/2022 and returning the same day. The licensee followed the absentee notification plan as necessary.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kandy Franklin | Administrator | Met with Licensing Program Analyst during the visit and involved in the incident follow-up. |
| Iby Strong | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| John Rante | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Plan of Correction
Census: 59
Capacity: 68
Deficiencies: 1
Dec 21, 2022
Visit Reason
An unannounced Case Management visit was conducted to verify a Plan of Correction following a previous Complaint visit.
Findings
The two Type B deficiencies cited during the complaint visit on 2022-12-14 were observed to be corrected and have been cleared.
Severity Breakdown
Type B: 2
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited 87303(a) and 87625(b)(3) were corrected and cleared. | Type B |
Report Facts
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kandy Ducharme-Franklin | Administrator | Met with Licensing Program Analyst during the visit and discussed the purpose of the visit |
| Iby Strong | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| John Rante | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 68
Deficiencies: 0
Nov 21, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not protect a resident resulting in fractured ribs and that the licensee did not report the resident's change in condition to the responsible party.
Findings
The investigation included interviews, records review, and a facility tour. The evidence did not support the allegations, and the complaint was deemed unsubstantiated based on staff interviews, medical records, and family statements.
Complaint Details
The complaint involved allegations that staff failed to protect a resident who sustained fractured ribs and failed to notify the responsible party of the resident's condition change. The investigation found no substantiation for these allegations.
Report Facts
Capacity: 68
Census: 58
Complaint Control Number: 08-AS-20211101095744
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jenna Purnell | Wellness Coordinator | Facility staff member met during the investigation and exit interview |
| Kandy Ducharme-Franklin | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 56
Capacity: 68
Deficiencies: 0
Oct 14, 2022
Visit Reason
An unannounced Required 1-Year Visit was conducted to evaluate the facility's compliance with licensing requirements, including infection control measures.
Findings
No deficiencies were cited or observed during the inspection. The Licensing Program Analyst evaluated the facility's infection control mitigation plan and provided consultation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Castillo | Wellness Director | Met with Licensing Program Analyst during the inspection and received a copy of the report. |
| Kandy Ducharme-Franklin | Administrator | Arrived shortly after the visit began and was present during the inspection. |
| Iby Strong | Licensing Program Analyst | Conducted the unannounced Required 1-Year Visit and authored the report. |
| John Rante | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 68
Deficiencies: 0
Sep 28, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not seek timely medical attention for a resident who fell out of his/her wheelchair and hit his/her head.
Findings
The investigation found that the resident was assessed by staff shortly after the fall, with only a red bump noted on the forehead. The hospice agency was notified promptly, and a hospice nurse visited the resident the same evening with no signs of injury or complications. The allegation was unsubstantiated due to lack of evidence of delayed medical attention or injury.
Complaint Details
The complaint alleged that the facility did not seek timely medical attention for a resident who fell and hit his/her head. The investigation concluded the allegation was unsubstantiated due to lack of evidence of delay or injury.
Report Facts
Complaint Control Number: 08-AS-20200716113029
Capacity: 68
Census: 55
Time of visit start: 11:13 AM
Time of visit completion: 11:30 AM
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Segura | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kandy Franklin | Executive Director | Facility representative met during investigation and exit interview |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 68
Deficiencies: 1
Sep 28, 2022
Visit Reason
The visit was a case management visit conducted to cite a deficiency observed during a complaint investigation regarding inaccurate documentation related to a resident's hospice call.
Findings
The facility documented a call to the hospice agency 50 minutes earlier than hospice records indicated, resulting in a citation for maintaining inaccurate documentation posing a potential health and safety risk.
Complaint Details
The visit was triggered by a complaint investigation. The deficiency cited was related to inaccurate documentation discovered during the complaint investigation. Substantiation status is not explicitly stated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee documented false information in records maintained for 1 of 55 residents, posing a potential health and safety risk. | Type B |
Report Facts
Residents in care: 55
Facility capacity: 68
Plan of Correction due date: Oct 14, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kandy Franklin | Executive Director | Met with Licensing Program Analyst during the visit and discussed the purpose of the visit |
| Dawn Segura | Licensing Program Analyst | Conducted the case management visit and cited the deficiency |
| Lizzette Tellez | Licensing Program Manager | Supervisor and Licensing Program Manager named in the report |
Inspection Report
Census: 56
Capacity: 68
Deficiencies: 0
Aug 4, 2022
Visit Reason
The visit was a Case Management - Incident type conducted due to a fire that occurred in Building B of the facility on 08/03/2022, which required health and safety checks and evaluation of the affected areas.
Findings
The fire was contained to Building B's front entrance with no injuries to residents. The affected area was cordoned off, and electrical repairs were confirmed to be completed. No deficiencies were cited or observed during the visit.
Report Facts
Residents evacuated from affected building: 23
Residents in adjacent buildings: 34
Number of buildings on property: 6
Time fire department cleared fire: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kandy Ducharme-Franklin | Administrator | Met with Licensing Program Analyst during the visit |
| Iby Strong | Licensing Program Analyst | Conducted the Case Management Visit |
| John Rante | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 68
Deficiencies: 1
Jun 21, 2022
Visit Reason
The visit was an unannounced Case Management visit conducted during a complaint investigation regarding an incident where a resident left the facility unassisted and the incident was not reported to Community Care Licensing.
Findings
The investigation found that Resident 1 left the facility unassisted on 2022-06-11 and this was not reported to the licensing agency, constituting a deficiency under Title 22, Division 6, Chapter 8 of the California Code of Regulations.
Complaint Details
The complaint investigation substantiated that the licensee did not report the unexplained absence of Resident 1, which poses a potential health and safety risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report an unexplained absence of Resident 1 to the licensing agency, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 68
Census: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kandy Ducharme-Franklin | Administrator | Met with Licensing Program Analyst during the visit and named in relation to the deficiency |
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| John Rante | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 59
Capacity: 68
Deficiencies: 0
Feb 25, 2022
Visit Reason
The visit was an unannounced Case Management visit to discuss an incident report received regarding a resident who was found missing (AWOL) during a resident check.
Findings
The resident was located approximately two blocks away from the facility, was intoxicated and displaying erratic behavior, and was transported to a psychiatric hospital. A care plan was created to address the AWOL occurrence. No deficiencies were cited during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kandy Duchareme-Franklin | Administrator | Met with Licensing Program Analyst during the visit and discussed the incident. |
| Debbie Correia | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Simon Jacob | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 59
Capacity: 68
Deficiencies: 0
Oct 5, 2021
Visit Reason
Licensing Program Analyst Kennedy made an unannounced visit to the facility to conduct an annual required licensing inspection.
Findings
No deficiencies were observed at this time in the areas evaluated, including infection control procedures, symptom screening, hand hygiene, PPE supplies, and disinfection procedures.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Castillo | Wellness Coordinator | Met with Licensing Program Analyst during inspection and discussed the purpose of the visit. |
| Anna Kennedy | Licensing Program Analyst | Conducted the unannounced annual required licensing inspection. |
Inspection Report
Plan of Correction
Capacity: 68
Deficiencies: 0
Jul 23, 2021
Visit Reason
An unannounced visit was made to verify that the conditions of a Plan of Correction (POC) were met at the facility.
Findings
The Plan of Correction was cleared during the visit, and no violations were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kandy Franklin | Administrator | Discussed the purpose of the visit and participated in the exit interview. |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 68
Deficiencies: 2
Jul 14, 2021
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the facility was not kept clean and was not kept free of insects.
Findings
The Licensing Program Analyst observed a general state of uncleanliness throughout the facility including sticky floors, toilets with feces, bugs in living areas, and stained floors, bathrooms, and showers with solid and/or liquid waste. These allegations were substantiated based on the evidence.
Complaint Details
The complaint was substantiated based on observations of uncleanliness and insect presence, meeting the preponderance of the evidence standard.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| 87303 Maintenance and Operation (a): The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by soiled floors with liquid and solid waste, and toilets with feces posing a potential risk to residents. | Type B |
| 87303 Maintenance and Operation (f)(1): Solid waste shall be disposed of in a manner that will not provide a breeding place or food source for insects. This requirement was not met as evidenced by food waste in resident rooms with insects present, posing a potential risk to residents. | Type B |
Report Facts
Residents at risk: 55
Facility capacity: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kandy Franklin | Administrator | Met with Licensing Program Analyst during the complaint investigation and named in findings. |
| Anna Kennedy | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report. |
| Paula McKnight | Maintenance Supervisor | Accompanied the Licensing Program Analyst during the facility tour. |
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