374604083-10-9-2025-08-AS-SJAB-DMEMVS-20251013095709

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 10/09/2025
Date Signed: 10/09/2025 05:00:59 PM

Unsubstantiated

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
07/22/2025 and conducted by Evaluator Amy Rodgers

COMPLAINT CONTROL NUMBER: 08-AS-20250722100127

FACILITY NAME:	MONTERA, THE		FACILITY NUMBER:	374604083
ADMINISTRATOR:	ALLEN, CATHY		FACILITY TYPE:	740
ADDRESS:	5740 LAKE MURRAY BLVD		TELEPHONE:	(619) 832-2599
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	225	CENSUS:	DATE:	10/09/2025
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Memory Care Director, Noe Romero.		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not properly dispensing medications to residents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Memory Care Director, Noe Romero.

On 7/22/2025, it was alleged that staff were not properly dispensing medications to residents. More specifically, it was reported that staff crushed multiple medications into yogurt, did not reattempt administration following a refusal, and failed to offer a missed dose later in the day to Resident #1(R1) on 6/22/2025 and 7/28/2025.

The investigation included a review of the facility’s Medication Administration Records (MARs) for June and July 2025, including the specific dates noted in the complaint, as well as care notes, staff interviews, and facility policies and procedures.
(continued on (LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

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 2

Control Number 08-AS-20250722100127

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: MONTERA, THE	FACILITY NUMBER: 374604083
	VISIT DATE: 10/09/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(continued from LIC 9099)

Although R1 has cognitive impairment, documentation showed that staff made reattempts to administer the medications, which R1 continued to refuse. Staff followed internal medication protocols and documented the refusals appropriately. There was no evidence that staff failed to administer medications as prescribed or disregarded resident refusals.

Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred; therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Noe Romero, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISOR'S NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2