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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603724
Report Date: 03/11/2026
Date Signed: 03/11/2026 01:56:16 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
07/28/2021 and conducted by Evaluator Becky Kennedy
COMPLAINT CONTROL NUMBER: 08-AS-20210728124213
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: 17DATE:
03/11/2026
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Risa JesterTIME COMPLETED:
03:06 PM
ALLEGATION(S):
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- Staff did not provide two-person assist for resident transfer.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint investigation visit to deliver findings on the above . LPA was granted entry to the facility and met with Risa Jester, Executive Director, after identifying herself and explaining the reason for the visit.
The Department’s investigation consisted of review of facility records, outside source records, and interviews of facility staff and outside sources.
It was alleged that facility staff did not provide two-person assist for resident transfer.
A review of facility records revealed thar Staff 1 (S1) did transfer Resident 1 (R1) without assistance. R1’s care plan requires a two-person transfer for the safety of R1 and staff members.
The allegation is therefore Substantiated, and one (1) deficiency was cited for it per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee.
An exit interview was conducted with Risa Jester a copy of this report and Licensee's Rights (LIC9058) were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jerry Romero
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
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-20210728124213
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: 03/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/12/2026
Section Cited
CCR
87464(d)
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87464 Basic Services (d)
… if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs …
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Executive director will implement their discipline policy with S! including additional training and a written performance Improvement plan.
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Based on a review of facility records, S1 transferred R1 without the assistance of another staff member, in violation of R1’s care plan and potentially compromising one of twenty-eight residents in care’s safety.
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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: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
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
07/28/2021 and conducted by Evaluator Becky Kennedy
COMPLAINT CONTROL NUMBER: 08-AS-20210728124213

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: DATE:
03/11/2026
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:TIME COMPLETED:
03:06 PM
ALLEGATION(S):
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- Facility did not administer medications as prescribed.
- Facility staff did not follow physician's orders.
- Facility staff did not follow resident's care plan.
- Facility did not store resident's medication.
- Staff did not ensure resident was hydrated.
- Residents documents were inaccurate.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint investigation visit to deliver findings on the above allegations. LPA was granted entry to the facility and met with Risa Jester, Executive Director, after identifying herself and explaining the reason for the visit.
The Department’s investigation consisted of review of facility records, outside source records, and interviews with facility staff and outside sources.

It was alleged that the facility staff did not administer medications as prescribed. Specifically that Resident 1 (R1) was prescribed specific shampoo that was to be used to wash R1’s hair and face, and that facility staff did not use the prescribed shampoo on R1’s face. A review of the physician’s orders regarding the prescribed shampoo was only for R1’s hair not washing R1’s face. This allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jerry Romero
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20210728124213
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: 03/11/2026
NARRATIVE
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It was further alleged that facility staff did not follow physician's orders by not insuring resident used Compression Socks
Interviews with staff report that they put R1’s compression socks on in the morning, and removed them at night, care staff washed the socks so they would be clean for the morning. This is consistent with resident’s care plan. This allegation is Unsubstantiated

It was alleged that facility staff did not follow resident's care plan. Specifically that R1 was in the bathroom and a care giver was further away from the bathroom that they should have been.
Interviews and a review of the resident’s care plan states that staff will “Provide as much privacy as possible during bathing” for R1. This allegation is Unsubstantiated.

It was further alleged that the facility did not centrally store resident's medication. Specifically that R1’s prescription shampoo and another unidentified medication were in R1’s room.
Interviews revealed that medication is taken directly to the med room upon arrival from the pharmacy. Prior to R1’s bathing, facility staff get the prescription shampoo from the medication room and when the care has been provided return it to the medication room. No information was revealed that any other medication was in R1’s room when it should have been centrally stored. This allegation is Unsubstantiated.

It was further alleged that facility staff did not ensure R1 was hydrated as evidenced by R1 being hospitalized for dehydration
Interview revealed numerous ways staff are trained to encourage liquid consumption by residents and to monitor for signs of dehydration. A review of the “after visit summary” from the period of hospitalization that was specific to this allegation does not mention dehydration as a cause of the hospitalization, R1 was discharged with new medication and referral to a hospice agency. This allegation is Unsubstantiated.

Lastly it was alleged that resident’s documents were inaccurate. Specifically that S2 logged that they had come in to assist R1 when S2 did not.
Interviews determined that there were logs in R1’s room that were placed there by an outside source. Any such logs or other documents are not facility documentation. No evidence was revealed that the facility’s documentation was not completed accurately. This allegation is Unsubstantiated.
SUPERVISORS NAME: Jerry Romero
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 08-AS-20210728124213
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: 03/11/2026
NARRATIVE
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Based on interviews and a review of documentation above allegations are UNSUBSTANTIATED meaning that the evidence did not meet the preponderance of evidence standard and is insufficient to compel further action.

An exit interview was conducted with Risa Jester; 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: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5