374604083-3-7-2022-08-AS-IESA-CDY5AR-20220429194733

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 03/04/2022
Date Signed: 03/07/2022 07:44:16 AM

Substantiated

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
09/13/2021 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20210913122136

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 requirements related to electrical power outage.

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 complainant alleged that during an electrical power outage on the night of September 11, 2021, licensee was unprepared to provide emergency lighting or to provide electrical power for residents’ assistive medical devices. CDSS’s investigation consisted of observation of the facility physical plant, and interviews of managers and frontline employees from various roles. CDSS also reviewed the facility’s LIC610E Emergency Disaster Plan and disaster drill records. The evidence revealed that while licensee maintained the means to power medical devices during the outage, licensee fell short of emergency lighting requirements.

[CONTINUED ON LIC 9099-C, 1 of 2]

Substantiated

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)

Page: 1 of 4

Control Number 08-AS-20210913122136

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] On September 22, 2021, LPA conducted an unannounced tour of the facility, during daylight hours. LPA interacted with the facility Staff #1 (S1) and facility Staff #2 (S2). At the time of the visit, S1 was the highest-ranked manager present and the administrator on duty, and S2 was the highest-ranked direct care staff present. LPA kindly asked S1 to present a flashlight and/or battery-operated light, then accompanied them as they searched. After 20 minutes of searching multiple floors and buildings of the facility campus (LPA did not set a time limit), to include asking S2 and other front-line direct care staff for help, S1 was unable to locate a single flashlight or battery-operated light. With S1’s consent, LPA then concluded the exercise.

Later during that same visit, facility managers Staff #4 (S4) and Staff #5 (S5) arrived at the facility. S5 correctly stated that flashlights were stored in the first and second floor medication rooms of Building B, then led LPA to these areas. LPA observed: a) In the 1st floor medication room were 7 flashlights, of which 3 were inoperable, and 1 contained a tablespoon of rust-colored acid corrosion dust in its battery compartment; b) In the 2nd floor medication room were 9 flashlights, of which 3 were inoperable; and c) Flashlights in both locations used either D cell batteries, AA batteries, or 6-volt batteries. S3 and S5 verbally corroborated what LPA observed: that there were no spare batteries in either medication room. S3 and S5 both said spare batteries are kept at the facility’s lobby front desk. LPA then spoke to the concierge receptionist on duty, who was unable to locate a single battery, or battery-operated light, at the front desk. According to the facility administrator, Staff #3 (S3), there were 162 residents in care on the date of the visit.

Staff interviews unanimously corroborated: a) an electrical power outage indeed occurred around 10:00 PM on September 11, 2021, b) the facility’s emergency generator activated to illuminate sconce lights in common area hallways (but not resident bedrooms), c) normal electric power was restored within the hour, and d) no resident suffered an adverse health-consequence as a result of the outage. Interviews with managers S1, S3, and S4 revealed that the facility was equipped with specific wall outlets, denoted by their red-colored plastic faceplates, which remain powered by the emergency generator during a general outage. During the facility tour, LPA witnessed multiple such outlets, intact, located in multiple buildings of the facility campus. These outlets were also described in the facility’s LIC610E Emergency Disaster Plan. Licensee articulated a sound plan to maintain continuity of electricity for resident assistive medical devices during a power outage, and thus met the requirements of California Health and Safety Code Section 1569.695(a)(7)(F). [CONTINUED ON LIC 9099-C, 2 of 2]

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)

Page: 2 of 4

Control Number 08-AS-20210913122136

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-C, 1 of 2]

S1, S3, and S4 also stated that residents (or their responsible parties) are asked to bring their own flashlights for private use during the move-in process, but the evidence revealed that this strategy was ineffective. LPA polled 15 frontline staff on whether a simple majority (i.e. more than 50%) of current residents kept their own flashlights in their rooms, in practice. 9 of 15 staff said most residents did not have flashlights in their rooms, while 2 of 15 staff were undecided. Staff interviews consistently revealed that the 1st and 2nd floor medication rooms of Building B, where the facility’s few working flashlights were (eventually) located, normally stay locked. Medication technicians and nurses carry keys to these rooms, but basically-trained caregivers do not (the latter group represents majority of all active staff on 3 of 3 work shifts each day). Multiple interviews corroborated that direct care staff on duty during the September 11, 2021 power outage tried but were unable to locate flashlights, either provided by the facility or by the residents themselves. These caregivers resorted to using their personal smart phones to illuminate dark resident bedrooms, where virtually all the facility’s residents were situated during the outage.

Based on LPA’s observations, staff interviews, and review of facility records, a preponderance of evidence exists to support the allegation that licensee did not fully meet requirements related to electrical power outage, specifically emergency lighting. The allegation is therefore 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 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)

Page: 3 of 4

Control Number 08-AS-20210913122136

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/03/2022 Section Cited CCR 87303(h)	1 2 3 4 5 6 7	87303(h) Maintenance and Operation: “Emergency lighting shall be maintained. At a minimum, this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff.” This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator shall: a) place one battery-operated light in every resident bedroom, b) maintain 15 battery-operated headlamps, storing them in areas directly accessible to caregivers, c) maintain an additional 10 battery operated flashlights or lanterns, d) maintain spare batteries for all of the above in areas directly accessible to caregivers, and e) retrain managers and frontline staff on the location of emergency lighting and batteries. Administrator will submit to LPA a training sign in sheet, purchase receipts, and/or photographic evidence supporting the above, by the POC due date.
	8 9 10 11 12 13 14	Based on LPA observations and interviews, licensee did not ensure working battery-powered lighting was readily available to its staff and 162 of 162 residents in care, which posed a potential impact on the facility’s plan of operation.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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.

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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4