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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603724
Report Date: 01/12/2026
Date Signed: 01/12/2026 02:39:57 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
04/02/2021 and conducted by Evaluator Becky Kennedy
COMPLAINT CONTROL NUMBER: 08-AS-20210402112310
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: 18DATE:
01/12/2026
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Karen MoranTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility did not meet resident's hygiene needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint investigation visit to the facility to deliver findings regarding the above allegation. LPA was granted entry to the facility after identifying herself. LPA met with Karen Moran, LVN Cognitive Entrenchment Director and explained the reason for the visit.

The Department’s investigation consisted of LPA observations, a review of facility and outside source records, and interviews of internal and outside sources.

It was alleged that the facility did not meet resident's hygiene needs. Specifically, that the facility did not provide for or arrange for proper foot care resulting in Resident 1’s (R1) toenails being uncut and grown significantly beyond the ends of R1’s toes. The investigation determined through interviews and a review of internal and external documents that at the time of R1’s admission to the facility consent was given for R1 to receive podiatry care from an outside provider.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jerry Romero
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026
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-20210402112310
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: 01/12/2026
NARRATIVE
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 R1 received podiatry care approximately every two months for a total of four podiatry visits. For reasons that could not be ascertained R1 did not receive any podiatry care after those visits. Interviews revealed that all residents were to receive podiatry care from the identified outside provider unless alternative arrangements had been made. There was not evidence that alternative arrangements were made for R1’s podiatry needs. The investigation did not reveal any evidence of R1 receiving any podiatry care for the last year of R1’s residency in the facility.

The investigation revealed the condition of R1’s feet at the time R1 moved out of the facility was consistent with a lack of podiatry care to meet R1’s foot care needs. This condition was the result of the facility’s failure to arrange such care. The allegation is SUBSTANTIATED. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D).

An exit interview was conducted with Karen Moran, LVN Cognitive Entrenchment Director a copy of this report and Licensee's Rights (LIC9058) were provided.
SUPERVISORS NAME: Jerry Romero
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20210402112310
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: 01/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2026
Section Cited
CCR
87464(c)(6)
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(c) "Care and supervision" means the facility assumes responsibility for… ongoing assistance with activities of daily living without which the resident’s physical health, … or welfare would be endangered. Assistance includes … personal care. (6) Arrangements to meet health needs…
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Facility will add checking hands and feet as part of the monthly skin checklist. The facility will do an inservice trqaining for all caregivers regarding foot care and what issues need to be elivated to nursing staff by POC date. Documentation will be submitted to CCL by POC date.
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Based on records and interviews the licensee did not arrange for the provision of podiatry care as needed in 1 of 23 persons in care (R1) which posed an potential risk to the health of 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: Jerry Romero
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 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
04/02/2021 and conducted by Evaluator Becky Kennedy
COMPLAINT CONTROL NUMBER: 08-AS-20210402112310

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: 18DATE:
01/12/2026
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Karen MoranTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not provide incontinence care
Staff did not keep facility free from incontinence odor
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint investigation visit to the facility to deliver findings regarding the above allegations. LPA was granted entry to the facility after identifying herself. LPA met with KKaren Moran, LVN Cognitive Entrenchment Director, and explained the reason for the visit.

The Department’s investigation consisted of LPA observations, a review of facility and outside source records, and interviews of internal and outside sources.

It was alleged that facility staff did not provide incontinence care to Resident 1 (R1). Interviews with internal and external sources revealed that residents are checked every two hours to assess their toileting needs. No concerns regarding resident incontinence care were revealed during the investigation. A review of documents did not reveal any skin breakdown for R1, or other indications of inadequate incontinence care. This allegation is Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jerry Romero
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026
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-20210402112310
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: 01/12/2026
NARRATIVE
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It was also alleged that facility staff did not keep facility free from incontinence odor. Interviews with internal and external sources and LPA observations did not reveal any concern about odor in the facility on a regular or ongoing basis. This allegation is unsubstantiated.

Based on the evidence obtained during the complaint investigation, the above allegations are UNSUBSTANTIATED, meaning the preponderance of evidence standard was not met.

An exit interview was conducted with Karen Moran, LVN Cognitive Entrenchment Director, a copy of this report and Licensee's Rights (LIC9058) were provided.
SUPERVISORS NAME: Jerry Romero
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5