374604083-3-24-2025-08-AS-SJAB-DG8VHA-20250430162648

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 03/18/2025
Date Signed: 03/24/2025 09:31:27 AM

Unsubstantiated

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
12/10/2024 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20241210155332

FACILITY NAME:	MONTERA, THE		FACILITY NUMBER:	374604083
ADMINISTRATOR:	EMILY TURNER		FACILITY TYPE:	740
ADDRESS:	5740 LAKE MURRAY BLVD		TELEPHONE:	(619) 832-2599
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	225	CENSUS: 186	DATE:	03/18/2025
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Aileen Spence Associate Executive Director		TIME COMPLETED:	01:36 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Executive Director does not treat resident with respect.
Executive Director retaliated against resident for making a complaint.
Executive Director spoke to resident in an inappropriate manner.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver investigative findings. LPA was granted entry into the facility and met with Associate Executive Director Aileen Spence, to whom LPA disclosed the reason for the visit.

On December 10, 2024, Community Care Licensing (CCL) received a complaint alleging the Executive Director does not treat resident with respect. Executive Director retaliated against resident for making a complaint and Executive Ddirector spoke to resident in an inappropriate manner. The Department’s investigation consisted of unannounced facility tours, review of facility records, resident interviews, staff interviews, outside agency interviews, and LPA direct observations.

(Continued on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025

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 3

Control Number 08-AS-20241210155332

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: 03/18/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Continued from LIC9099 page 2 of 3)

Regarding the first allegation, Executive Director (ED) did not treat resident with respect. Direct observation by LPA as well as outside source interviews, resident interviews, and staff interviews, did not show that the facility ED was not meeting the identified expectations put forth by the facility regarding the personal rights of every resident to be treated with respect.

Residents interviewed confirmed that facility ED was nice and interacted with them in a positive and respectful manner. Staff interviews indicated that residents were treated with positive regard and that the ED exhibit patience and enjoy spending time with them. Outside source interviews and witness interviews showed that ED was observed treating resident with respect and in a positive manner.

A review of facility records showed that ED completed a series of on boarding and continuous training that reinforces the basic rights of residents and how to interact with residents based on their developmental needs. ED also agreed to the facility community standards which outline specific characteristics of acceptable and expected behavior.

During unannounced facility visits, LPA observed the ED to be engaging with residents in a positive and respectful manner. LPA did not observe the ED reacting with residents in a way that would indicate a negative or unpleasant dynamic. LPA observed a poster of staff expectations which address the positive treatment of others to be in a visible location for staff to view regularly.

Regarding the second allegation staff retaliated against resident for making a complaint. Direct observation by LPA as well as outside source interviews, resident interviews, staff interviews, and records review, did not demonstrate that staff retaliated against resident for making a complaint.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20241210155332

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: 03/18/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Page 3 of 3)

Resident interviews confirmed that facility staff are not retaliating against resident for making a complaint. Staff interviews showed they have not observed any forms of retaliation against resident for making a complaint. Outside source interviews and witness interviews showed they have not observed any forms of retaliation against resident for making a complaint.

Review of facility records showed that staff complete training regarding resident rights and appropriate ways to work with the elderly residents. Staff document residents’ demanding behavior and how to manage the resident based on individual needs.

During 4 unannounced facility visits LPA directly observed staff interaction with the residents to be respectful. There were no signs of retaliation or demeaning gestures.

Regarding the third allegation, Staff spoke to resident in an inappropriate manner. Direct observation by LPA as well as outside source interviews, resident interviews, staff interviews, and records review, did not support the claim that facility staff spoke to resident in an inappropriate manner.

Resident interviews confirmed there have been no observations of staff speaking in an inappropriate manner to the resident. Review of facility records showed that staff complete training on resident rights and working with the elderly population.

During 4 unannounced facility visits, LPA directly observed staff walking around engaging with residents, assisting with ADLs, and instructing group activities. LPA directly observed residents asking staff members for assistance and receiving help immediately or within minutes of the request. There were no observations of staff speaking with residents in an inappropriate manner.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are therefore UNSUBSTANTIATED. An exit interview was conducted with Aileen Spence, Associate Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3