374604083-3-19-2025-08-AS-SJAB-DF4QAD-20250325115944

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 03/18/2025
Date Signed: 03/19/2025 10:03:56 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
10/28/2024 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20241028151716

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:	08:15 AM
MET WITH:	Alleen Spence Associate Executive Director		TIME COMPLETED:	11:02 AM

ALLEGATION(S):

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The facility staff did not provide resident reappraisal upon change in condition.

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 Aleen Spence, Associate Executive Director, to whom LPA disclosed the reason for the visit.

Community Care Licensing (CCL) has investigated the above listed complaint allegation. The investigation consisted of review of facility staff and resident records, interviews with residents, staff, and outside sources.

On October 28, 2024, Community Care Licensing (CCL) received a complaint alleging facility staff did not provide resident reappraisal upon change in condition.

(Continue on LIC9099C)

Substantiated

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 4

Control Number 08-AS-20241028151716

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

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(Continued page 2 of 3)

A review of Resident 1 (R1) needs and services plan addressing demanding behavior was added on September 6, 2024. The service plan did not have any signatures that would confirm the resident, responsible party, and facility representative were made aware of the change of condition.

A review of Resident 1 (R1) resident assessment, dated September 19, 2024, indicated R1 and Outside Source 1 (OS1) did not sign the assessment. There is a handwritten note stating OS1 and R1 reviewed the assessment and did not agree with the psychosocial component of the assessment. The level assigned to R1 was a level four (4) with 197 points. The assessment was signed by two facility representatives.

A review of R1’s resident assessment completed on November 19, 2024, was agreed upon at a level four (4) with 170 points. The resident assessment was signed by OS1 and two community representatives.

A review of R1’s resident assessment completed on November 22, 2024, was not signed by OS1 but was signed by two facility representatives. The level on the assessment was three (3).

A review of the 30-day notice to terminate letter stated that a resident assessment was completed on December 20, 2024, but there were no documents provided when LPA Domingo requested them.

Staff 1 (S1) was interviewed, and they stated when R1 started exhibiting behavioral symptoms (accusatory towards staff, agitation towards staff, and angry outburst towards staff), they decided to assign two (2) caregivers when assisting R1. LPA Domingo asked if there was a care conference held to discuss the changes with R1’s behaviors. S1 stated at the time the decision was made, there was not a care conference in place. The interview with S1 revealed the MD was not informed of the behavioral change and OS1 was not informed at the time of the change of condition.

During an interview R1 stated they were not made aware of a behavioral change until the review of the resident assessment dated September 19, 2024. R1 stated two (2) caregivers started showing up to assist them on September 5, 2024.

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 4

Control Number 08-AS-20241028151716

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

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(Continue page 3 of 3)

OS1 was interviewed and stated the staff at the facility did not notify them of a behavioral change that needed two (2) caregivers with R1. After the second care conference held on September 12, 2024, the level for R1 was said to be a six (6). OS1 requested documentation on the determination of the level of care and the facility staff stated they did not have a copy.

The resident assessment on September 19, 2024, was not signed, they did not agree with the psychosocial component of the assessment. OS1 stated that upon admission they were told R1 was at a level two (2). On November 19, 2024, the level for R1 was at four (4). Two days later the level changed to three (3). OS1 stated that there was another resident assessment conducted on December 20, 2024, but there are no records to show that the assessment was completed.

The Department investigated the above allegation, and the preponderance of the evidence standard was met, proving that the alleged violation occurred. Therefore, the above allegation is substantiated. Deficiency cited in accordance with the California Code of Regulations, Title 22 and are on the attached 9099-D. An exit interview was conducted with Aileen Spence Associate Executive Director and a plan of correction was jointly developed. A copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.

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)

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Control Number 08-AS-20241028151716

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: 03/18/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/18/2025 Section Cited CCR 87463	1 2 3 4 5 6 7	Reappraisals (f) Licensee shall immediately communicate with the resident and the resident's representative about any significant change in condition, the recommendation of the appropriate licensed medical professional, and other specialized care provider. Documentation of communication shall be added to the resident’s record.	1 2 3 4 5 6 7	The Licensee agrees to schedule reappraisal training with management staff within 30 days. The scheduled date of training and name of vendor will be submitted to CCLD by POC due date 4/18/25
	8 9 10 11 12 13 14	This requirement was not met as evidence by: Based on staff/resident interviews and records reviewed, the licensee did not ensure that 1 of 180 residents were reappraised when a change of condition occurred. This poses a potential health and safety for residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 03/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025

LIC9099 (FAS) - (06/04)

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