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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603724
Report Date: 06/04/2025
Date Signed: 06/04/2025 01:10:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2023 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230613182530
FACILITY NAME:MONARCH COTTAGES LA JOLLAFACILITY NUMBER:
374603724
ADMINISTRATOR:RISA BISHOPFACILITY TYPE:
740
ADDRESS:7630 FAY AVENUETELEPHONE:
(858) 924-8530
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:52CENSUS: 23DATE:
06/04/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Executive Director RIsa JesterTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Neglect/Lack of Supervision resulted in resident sustaining serious injury.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Iby Strong and Arian Golbakhsh conducted an unannounced complaint visit to deliver findings in the above-mentioned allegation. LPAs met with Executive Director RIsa Jester and discussed the purpose of the visit.

On June 13, 2023, Community Care Licensing (CCL) received a complaint alleging neglect/lack of supervision resulted in Resident 1 (R1) (R1 – see LIC811 Confidential Names List) sustaining serious injuries. According to R1’s Physician Report, R1 is diagnosed with a major neurocognitive disorder, is non-ambulatory, and has motor impairment/paralysis. R1’s Needs and Services Plan states R1 is a total assist with activities of daily living and a two person assist with bathing, washing and toileting.

During investigation, the Department collected pertinent resident records as well as facility documentation and conducted interviews. According to the allegation, on an undisclosed date in May of 2023, R1 was being transported and dropped by an unknown staff, resulting in a fracture. According to interviews conducted by the Department, the following sequence of events took place.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 08-AS-20230613182530
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MONARCH COTTAGES LA JOLLA
FACILITY NUMBER: 374603724
VISIT DATE: 06/04/2025
NARRATIVE
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According to Staff 1 (S1) on April 28, 2023, between 7:30pm and 8:00pm, R1 was scheduled to receive a shower. S1 proceed to ask Staff 2 (S2) for assistance in transferring R1 from wheelchair to shower chair. Interview with S2 revealed that S2 assisted S1 in the transfer and left S1 alone to bathe R1. S1 stated that minutes later, S1 reached for a washcloth and as they reached away from R1, R1 fell from shower chair and hit head on the floor. S1 proceed to call for assistance from S2, Staff 3 (S3) and Staff 4(S4). S3 then assisted S1 and S2 in proving first aid to R1 and S4 contacted emergency personnel. R1 was then taken to be medically evaluated and received sutures to left forehead above the eye. According to medical records on April 29, 2023, at 2:56 am, R1 was discharged and returned to the facility with a diagnosis of laceration to the top of the left forehead. Interview with an outside source, confirmed R1 received medical care post fall.  
Facility status notes revealed that as of May 3, 2023, R1 refused to eat and drink. On May 5, 2023, R1’s responsible party requested for R1 to be evaluated by a medical professional and R1 was then sent out for additional medical follow up. Medical records revealed that at this time, R1 was diagnosed with a closed fracture of left hip and received surgery to treat the fracture.  

Based on staff and outside source interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation neglect/lack of supervision resulted in R1 sustaining a fracture and sutures as a result of not following R1’s care plan. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). 
 
The Department has determined this violation resulted in injuries to the resident in care.  An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM.  At this time, per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division. An exit interview was conducted with Executive Director RIsa Jester, and a Plan of Correction was jointly developed. A copy of this report, LIC811, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Executive Director RIsa Jester, signature on this form confirms receipt of documents. 
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20230613182530
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MONARCH COTTAGES LA JOLLA
FACILITY NUMBER: 374603724
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2025
Section Cited
CCR
87464(f)(4)
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(f) Basic services shall at a minimum include:(4)Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing...
This requirement was not met as evidence by:
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Licensee stated staff 1 has been terminated, and training has been provided since the incident for all care staff. Licensee will provide LPA with documentation of trainings within 24 hours.
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Based on records and interviews the licensee did not provide personal assistance and care as needed in 1 of 23 persons in care (R1) which posed an immediate Safetyisk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2023 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230613182530

FACILITY NAME:MONARCH COTTAGES LA JOLLAFACILITY NUMBER:
374603724
ADMINISTRATOR:RISA BISHOPFACILITY TYPE:
740
ADDRESS:7630 FAY AVENUETELEPHONE:
(858) 924-8530
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:52CENSUS: 23DATE:
06/04/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Executive Director Risa JesterTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff left resident soiled resulting in a rash.
Licensee did not treat pest
Licensee did not provide resident with dental care needs
Licensee did not meet resident's medical need.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Iby Strong and Arian Golbakhsh conducted an unannounced complaint visit to deliver findings in the above-mentioned allegations. LPAs met with Executive Director Risa Jester and discussed the purpose of the visit.

On June 13, 2023, Community Care Licensing (CCL) received a complaint alleging staff left Resident 1 (R1) soiled resulting in a rash, licensee did not treat for pest, licensee did not provide resident with dental care needs and licensee did not meet residents’ medical needs. According to R1’s Physician Report, R1 is diagnosed with a major neurocognitive disorder, is non-ambulatory, and has motor impairment/paralysis.

During investigation, the Department collected pertinent resident records as well as facility documentation and conducted interviews. According to the first allegation, R1 was observed to have a rash due to lack of incontinence care from facility staff.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20230613182530
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MONARCH COTTAGES LA JOLLA
FACILITY NUMBER: 374603724
VISIT DATE: 06/04/2025
NARRATIVE
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Interview with multiple staff revealed R1 returned from the hospital with a rash sometime in May of 2023. Records collected corroborated R1 was admitted to the hospital in May of 2023 where R1 received extended care for an unrelated medical issue. Interview with staff revealed residents are monitored for incontinence care every 2 hours.

It was also alleged that R1 was observed to have pest on their personal items. On June 6, 2023, LPA Strong conducted a facility inspection and did not observe any pests. Interview with multiple staff revealed they have not observed any pest. Interview with an outside source established that they have not seen any pest at the facility. On today’s date, LPAs conducted an additional facility inspection and did not observe any pests.

The third allegation states that R1 did not receive assistance with dental care needs. Records collected revealed R1 was scheduled and attended multiple dental appointment in 2023. Interview with staff revealed facility schedules regular dental appointments for residents and will provide transportation to such appointment.

Lastly, it was alleged R1 did not receive regular blood sugar monitoring. Interviews with staff revealed that R1 is diagnosed with diabetes but does not require continuous blood monitoring. Records collected corroborated that R1 is diagnosed with diabetes but does not have a diabetic diet or require monitoring. Medical records collected did not reveal any information to establish that facility was not providing adequate care for R1’s diabetic diagnosis.

Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove the allegations. An exit interview was conducted with Executive Director Risa Jester, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5