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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604083
Report Date: 02/22/2023
Date Signed: 02/24/2023 09:44:38 AM


Document Has Been Signed on 02/24/2023 09:44 AM - It Cannot Be Edited

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:EMILY TURNERFACILITY TYPE:
740
ADDRESS:5740 LAKE MURRAY BLVDTELEPHONE:
(619) 832-2599
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:225CENSUS: 182DATE:
02/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Emily Turner, Executive DirectorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced case management visit. LPA was granted entry into the facility by Emily Turner, Executive Director, with whom she disclosed the purpose of the visit.

Today’s visit was in response to an incident which licensee self reported via an LIC 624 Incident Report. The report described Resident #1 (R1 – See LIC 811 Confidential Names List for identification of R1) with pain on her ribs. During today's visit, LPA toured the facility, performed a welfare check on residents in care, and obtained copies of pertinent facility records. No immediate health and safety concerns were observed during the visit. No deficiencies were cited during the visit.

An exit interview was conducted with Emily Turner, Executive Director, and copies of this report and Licensee/Appeal Rights (LIC 9058 03/22) were provided to the Executive Director at the conclusion of the visit. Her signature on this form acknowledges receipt of the rights and a copy of the report.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
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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