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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 11/21/2024
Date Signed: 01/16/2025 08:42:11 AM

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
09/09/2024 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20240909102606
FACILITY NAME:MONTERA, THEFACILITY NUMBER:
374604083
ADMINISTRATOR:EMILY TURNERFACILITY TYPE:
740
ADDRESS:5740 LAKE MURRAY BLVDTELEPHONE:
(619) 832-2599
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:225CENSUS: 190DATE:
11/21/2024
UNANNOUNCEDTIME BEGAN:
11:36 AM
MET WITH:Sanjay Kabadi Executive DirectorTIME COMPLETED:
12:37 PM
ALLEGATION(S):
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Staff handled resident in an inappropriate manner.
Staff spoke to resident in an inappropriate manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver investigative findings. LPA was granted entry into the facility and met with Executive Director Sanjay Kabadi, to whom LPA disclosed the reason for the visit.

Community Care Licensing (CCL) has investigated the above listed complaint allegations. The investigation consisted of review of facility staff and resident records, interviews with residents, staff, and outside sources.
On September 9, 2024, CCL received a complaint alleging staff handled resident in an inappropriate manner.


This is an amended version of the original report provided to the licensee and signed on November 21, 2024.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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 3
Control Number 08-AS-20240909102606
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2024
Section Cited
CCR
87468.1(a)(1)
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87468.1 (a)(1) Residents in all residential care facilities for the elderly shall have all the following personal rights: To be accorded dignity in their personal relationships with staff. This requirement was not met as evidence by:

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The Licensee agrees schedule a resident rights training with a CCL approved vendor to provide training with all staff within 30 days. The scheduled date of training and name of vendor will be submitted to CCLD by POC due date, 2/20/25
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Based on interviews, the licensee did not ensure that 1 of 183 residents were accorded dignity in their personal relationships with staff. This poses a potential personal rights violation to residents in care.
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Type B
12/20/2024
Section Cited
CCR
87468.1(a)(3)
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87468.1 (a) (3) Residents in all residential care facilities for the elderly shall have all the following personal rights: To be free from punishment, humiliation, intimidation. This requirement was not met as evidence by:
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The Licensee agrees schedule a resident rights training with a CCL approved vendor to provide training with all staff within 30 days. The scheduled date of training and name of vendor will be submitted to CCLD by POC due date, 2/20/25
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Based on interviews, the licensee did not ensure that 1 of 183 residents was free from humiliation. This posed a potential personal rights violation to residents in care.
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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: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20240909102606
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: 11/21/2024
NARRATIVE
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Continued from LIC9099

A review of Resident 1 (R1) Physician’s Report, dated May 23, 2024, indicated that R1 is capable making their own decisions and communicating their needs. A R1’s primary diagnosis is Chronic right sided hemiplegia.

A review of care conference notes dated, on September 10, 2024, revealed R1 reported to licensee that Staff 1 (S1) handled them inappropriately and that S1 and Staff 2 (S2) made disparaging comments about R1 in their presence.

During an interview with R1, they reported sitting in their wheelchair facing the sink after washing their hands. They didn’t have a towel; therefore, they pressed the pendant for assistance and S2 responded. While R1 was telling S2 where to find the hand towels, S1 entered the room and stood behind R1, out of their line of sight. As R1 raised their hand to receive the towel, S1 reached over and touched R1’s hand to check if it was wet.  R1 stated they were startled and reacted by squeezing S1's hand.  S1, also startled, left the room immediately to report the incident to their supervisor. R1 expressed that no one should touch another person without their knowledge and stated that S1 did not have permission to touch their hands. 
During an interview, S2 confirmed R1 was washing their hands at the sink and had requested a hand towel. S2 stated S1 reached over to touch R1’s hand to show their hands were dry when R1 squeezed S1's hand. S2 stated R1 was not anticipating S1 to reach over to touch their hand without their knowledge. In a separate interview, with S1 explained that R1 had requested a hand towel to dry their hands. S1 stated that they told R1 their hand was already dry and while R1 was raising their voice, S1 reached over to feel R1’s hand without informing them beforehand. S1 stated that R1 reacted by squeezing their hand, S1 stated they pulled away and left the room.  
 
Staff 3 (S3) was interviewed and stated they conducted their own investigation, concluding that R1 had handled S1 in an inappropriate manner.  However, S3 admitted they did not interview R1, complete an incident report, or follow mandated reporting guidelines regarding a resident complaint of inappropriately staff handling.   

Staff 4 (S4) confirmed during interview that they did not interview R1 about the incident and stated they agreed with S3’s investigation findings.   
A review of staff records reviewed revealed that S1 and S2 had no documented poor performance reviews or disciplinary actions. Interviews with outside sources indicated no concerns regarding the care provided by staff at the facility.  

Outside Source 1 (OS1) stated that no records provided showing the facility had investigated the September 5, 2024, incident.  OS1 noted that R1 had a history of making factual statements. Outside Source 2 (OS2) also confirmed that R1 had no reason to make false statements. 

On September 9, 2024, CCL received a complaint alleging staff spoke to R1 in an inappropriate manner.  
During an interview with R1, they reported that on the evening of September 5, 2024, while S2 was assisting them with their hygiene routine, S2 commented that they would be late ending their shift because R1 was taking too long. R1 stated they found this comment inappropriate and told S2 that they pay their salary and to avoid rushing through their care. 

When interviewed, S2 initially denied making the statement but later admitted to saying they would be late getting off their shift.  

In an interview, S3 stated they conducted an internal investigation and concluded the staff did not speak to R1 in an inappropriate manner. S3 acknowledged they did not interview R1 but interviewed S1 and S2. S3 also admitted they did not complete an incident report or follow the mandated reporting guidelines regarding a resident complaint of inappropriate staff conduct manner. 

Staff 4 (S4) was also interviewed and stated they had no incidents of R1 making comments about paying their salary.  S4 reported maintaining a good rapport with R1 by allowing ample time for them to communicate their needs. 

The Department investigated the above allegations, and the preponderance of the evidence standard was met. Therefore, the above allegations are substantiated. Deficiencies were cited in accordance with the California Code of Regulations, Title 22 and are documented on the attached 9099-D. An exit interview was conducted with Executive Director Sanjay Kabadi and a plan of correction was jointly developed.  A copy of these reports along with Licensee/Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit. 
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3