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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604083
Report Date: 01/24/2020
Date Signed: 01/27/2020 09:29:35 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MONTERA, THEFACILITY NUMBER:
374604083
ADMINISTRATOR:JUDITH PIERFAXFACILITY TYPE:
740
ADDRESS:5740 LAKE MURRAY BLVDTELEPHONE:
(949) 242-1400
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:225CENSUS: 147DATE:
01/24/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Executive Director, Judith PierfaxTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Debbie Correia made an unannounced case management visit to the facility today. LPA was granted entry into the facility and met with Executive Director (ED), Judith Pierfax. LPA stated the purpose of the visit is to follow up on a Special Incident Report received on January 8, 2020.

On January Resident 1(R1) had an unwitnessed fall in their apartment resulting in a laceration to R1's head requiring staples. The Sharp Hospice Agency had recently required R1 to wear a wedge between legs to relieve pressure. R1 experienced the fall while trying to adjust the wedge. Facility staff followed protocol by notifying hospice, sending her out for medical attention and placing her on a 48 hour alert charting. R1 is currently residing at the facility with no further incidents.

Based on LPA's visit and a review of the incident reports and action taken by staff, no deficiencies are being cited during today’s visit.

An exit interview was conducted and a copy of this report was provided to ED Judith Pierfax. ED Judith Pierfax was provided a copy of their Licensee/Appeal Rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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