374604083-3-7-2022-08-AS-IESA-CDY5G8-20220429195617

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 03/04/2022
Date Signed: 03/07/2022 07:34:06 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/12/2021 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20211112135359

FACILITY NAME:	MONTERA, THE		FACILITY NUMBER:	374604083
ADMINISTRATOR:	MORGAN CADMUS		FACILITY TYPE:	740
ADDRESS:	5740 LAKE MURRAY BLVD		TELEPHONE:	(619) 832-2599
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	225	CENSUS: 179	DATE:	03/04/2022
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Executive Director Morgan Cadmus		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Licensee did not meet training requirements related to emergency procedures.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by and identified himself to concierge receptionist Keyla Frias. LPA then met with and discussed the purpose of the visit with Executive Director Morgan Cadmus.

The complaint was filed on November 12th, 2021. CDSS’s investigation consisted of an unannounced tour of the facility and interviews of staff from various job positions. The Department also reviewed training records and materials, fire drill records, the facility’s LIC610E Emergency Disaster Plan, among other documents.

The complainant alleged that licensee’s staff were not trained for emergencies, specifically on stairwell evacuation chairs. Interviews of the facility’s Executive Director (S1) and Director of Environmental Services (i.e. maintenance director) (S2) revealed that on July 29th, 2021, S2 led a training on the stairwell evacuation chair for front line staff at an “All Staff Meeting.” [CONTINUED ON LIC 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tellez Lizzette	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20211112135359

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MONTERA, THE	FACILITY NUMBER: 374604083
	VISIT DATE: 03/04/2022

NARRATIVE

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[CONTINUED FROM LIC 9099]

The training consisted of an instructional video on a large-screen projector, use of an actual evacuation chair as a visual aid, and answering questions. CDSS reviewed the sign-in sheet and meeting agenda for this day, which shows 21 front line staff attended. S2 trained them on “the evacuation chair,” as well as on prioritization during a fire and the correct use of a fire extinguisher. CDSS reviewed the above-mentioned training video, which was 3 minutes and 56 seconds long and produced by Evacuscape, the manufacturer of the facility’s evacuation chairs. CDSS also encountered photographic proof of the training, which showed S2 as a presenter and a frame of said training video in the background.

CDSS also interviewed 15 frontline staff comprising drivers, caregivers, med techs, housekeepers, and concierge receptionists: 5 of 15 said they attended the training with S2 on July 29th, 2021, and corroborated that it occurred as described by S1 and S2. Another 3 of 15 staff said they missed the July 29th, 2021 training, but attended a prior year’s training on the evacuation chair, also led by S2. Another 2 of 15 staff said they were unable to attend S2’s training due to being nocturnal staff – however, the facility’s Director of Health Services (S3) recently conducted a separate training class on the evacuation chair for the night shift, which they rated as effective. Another 1 of 15 frontline staff said they completed a computer training module on the evacuation chair. A few of the staff also said they possessed evacuation chair training from a former employer by time of hire. The evidence shows that by the time of the complaint and CDSS’ ensuing investigation, a majority of licensee’s frontline staff received training on the evacuation chair, and that licensee facilitated evacuation chair training for its staff more than once. According to records, licensee also performed quarterly disaster drills, engaging direct care staff from all three of its work shifts.

Based on LPA’s observations, staff interviews, and review of facility records, a preponderance of evidence does not exist to support the allegation that licensee did not meet training requirements related to emergency preparedness. The allegation is therefore unsubstantiated. An exit interview was conducted with Cadmus, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.

SUPERVISOR'S NAME: Tellez Lizzette	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

LIC9099 (FAS) - (06/04)

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