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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 01/14/2025
Date Signed: 01/16/2025 08:39:31 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
06/24/2024 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20240624162325
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: 183DATE:
01/14/2025
UNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Sanjay Kabadi Executive DirectorTIME COMPLETED:
05:09 PM
ALLEGATION(S):
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Facility staff did not administer medications as prescribed.
The facility did not assist in disseminating information about the family council meetings.
The facility did not assign a designated staff liaison to aid the family council.
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.

On June 24, 2024, Community Care Licensing (CCL) received a complaint alleging staff did not administer medications as prescribed. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, and outside sources.

A review of Resident 1 (R1) Physician’s Report dated May 23, 2024, indicated that R1 is able to make their own decisions and communicate their needs. Additionally, the report indicates that R1 is unable to store, administer or manage medications on their own. R1’s primary diagnosis is Chronic right sided hemiplegia.

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: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
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 4
Control Number 08-AS-20240624162325
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: 01/14/2025
NARRATIVE
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During an interview with R1, they reported multiple incidents involving improper medication administration at the facility. R1 recalled an incident occurred on or around August 1, 2024, when staff 4 (S4) dispensed medications without doing so in R1’s presence. R1 expressed concern stating they were unsure of the source of the medication in the pill container and requested that S4 repour it in their presence. Additionally, R1 reported missing two medications on August 12, 2024, due to incorrect pharmacy information on the MAR.

Five (5) staff members knowledgeable about medication administration were interviewed as part of the investigation. During the interviews, three (3) staff members stated that R1 did not miss any medications. One (1) staff member acknowledged not pouring R1’s medication R1’s presence. Another staff member confirmed that the Admission Agreement forms that were presented and signed during the admission process contained an incorrect pharmacy name.

During an interview, Outside Source 1 (OS1) reported that on July 9, 2024, R1’s physician clarified a medication order; however, facility staff did not update the medication order on record until July 19, 2024. OS1 stated that R1 missed two medications on August 12, 2024, because the facility provided OS1 with the incorrect pharmacy name.

A review of records revealed on June 13, 2024, R1 refused a medication, stating the facility had the wrong dose. R1 indicated that the medication was supposed to be administered three times a day, rather than two times a day. The records further confirmed that the physician clarified the order on July 9, 2024, but the facility did not update the medication record until July 19, 2024.

On June 24, 2024, CCL received a complaint alleging that the facility did not assist in disseminating information regarding family council meetings and did not assign a designated a staff liaison to aid the family council.

On June 25, 2024, LPA Domingo observed postcard invitations to the family council meeting placed at the front desk of the facility.

Four (4) family members were interviewed during the investigation. These outside sources corroborated the allegations, stating they were unaware of any family council meetings, or a designated staff liaison to aid with the family council.

An interview with Staff 1 (S1) revealed that family council postcards were placed only at the front desk on June 21, 2024. An interview with Staff 2 (S2) revealed that the facility had placed one family council information board at the front of the C building, along with postcards at the front desk detailing family council information and a contact person for the meetings. S2 explained that the family council is a family-led activity, and that facility staff do not get involved. S2 also confirmed that there was no designated staff liaison appointed to the family council and that information about the family council meetings was not included in mailings to residents or their designees.

Three (3) staff members were interviewed during the investigation, corroborated the allegations that the facility did not assist in disseminating information about the family council meetings, and did not assign a designated a staff liaison to aid the family council.

A review of three (3) records of recently admitted residents showed that none of the admission agreement were updated with information about the family council meetings, which started on July 15, 2024.

Two (2) family members were interviewed during the investigation stated they were aware of the newly established family council meetings through word of mouth but had no information regarding when or where the meetings were being held.

The Department investigated the above allegations and was able to meet the preponderance of the evidence standard. Therefore, the above allegations are substantiated. Deficiencies were cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8, and is noted on the attached LIC9099-D. An exit interview was conducted with Executive Director Sanjay Kabadi, which included jointly developing plans of correction. 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: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20240624162325
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: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
02/20/2025
Section Cited
CCR
87465(c)(2)
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87465 Incidental and Dental Care (c) (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by:
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The Licensee agrees to schedule a medication training with a CCL approved vendor (other than the preferred pharmacy) to provide training with Med Tech staff within 30 days. The scheduled date of training and name of vendor will be submitted to CCLD by POC due date of 2/20/25
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Based on record review and staff and resident interviews, the licensee did not ensure that once ordered by the physician the medication was given according to the physician's direction in 1 of 180 residents. This poses a Health risk to R1 in care.
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Type B
02/20/2025
Section Cited
HSC
1569.158(g)(1)
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… If a facility has a family council, the facility shall inform the resident and the resident’s representatives, family members, or other individuals designated by the resident or identified during the admission process of the existence of the family council. The facility shall provide the resident and those family members, friends, and resident representatives with the name and contact information of the family council representative, as designated by the family council, in writing, prior to or within five business days after the resident’s admission or the resident’s representative, family member, or other individual is designated or identified. When family council meeting information is provided by the family council, the facility shall include notice of family council meetings in routine mailings to those family members, friends, and resident representatives. The notice shall include the time, place, and date of meetings, and the name and contact information of the family council representative, as designated by the family council. This requirement was not met as evidence by:
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Based on records reviewed and interviews, the licensee did not ensure that 5 of 180 families or designees were provided information about family council meetings. This poses a potential personal right in residents in care.
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 The facility agrees to include family council information and contact information about family council in mailings, announcements, and newsletters to the family members and resident’s designees by 2/20/25.
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: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20240624162325
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: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
02/20/2025
Section Cited
HSC
15969.158(h)(2)(i)
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 If a facility has a family council and a licensed capacity of 16 or more, the facility shall appoint a designated staff liaison who shall be responsible for providing assistance to the family council and responding to written requests that result from family council meetings. A facility shall provide an alternate staff liaison as needed. This requirement was not met as evidence by:
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The facility agrees to assign a designated staff liaison who will be responsible for aiding the family council by 2/20/25
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Based on records and interview, the licensee did not ensure that 5 of 183 resident family members were provided a liaison for the family council meetings. This poses a personal rights risk to the resident 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: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4