374604083-6-2-2023-08-AS-DNGN-CSEUXX-20230602155903

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604083
Report Date: 06/02/2023
Date Signed: 06/02/2023 03:59:13 PM

Document Has Been Signed on 06/02/2023 03:59 PM - 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, 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: 190	DATE:	06/02/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Executive Director Emily Turner		TIME COMPLETED:	04:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Emily Turner.

Today's visit was in response to two (2) LIC624 Incident Reports which Licensee self-submitted to the CCLD San Diego Regional Office (RO). According to the first LIC624 (received at the RO on 01/20/2023): During the evening of 01/13/2023, an error by Staff #1 (S1) led to Resident #1 (R1) incorrectly receiving and ingesting medications which did not belong to them, but which were instead prescribed for a different resident. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. R1 did not experience any adverse side-effects or negative health consequence from this incident. According to the second LIC624 (received at the RO on 02/21/2023): During the evening of 02/10/2023, an error by Staff #2 (S2) led to Resident #2 (R2) incorrectly receiving and ingesting their AM shift medications, instead of their prescribed PM shift medications. R2 did not experience any adverse side-effects or negative health consequence from this incident.

During today’s visit, LPA performed a brief facility tour and welfare check on R1 and R2, verifying that both were safe/unharmed. LPA also collected copies of pertinent resident and employee records and interviewed relevant staff. Due to their baseline memory loss, neither R1 nor R2 were able to participate as reliable historians/interviewees.

According to their latest respective LIC602 Physician’s Report’s: R1 was diagnosed with “cognitive communication deficit,” was “confused/disoriented,” and required staff assistance with taking their prescribed medications. R2 was diagnosed with “Mild Cognitive Impairment” and required staff assistance with taking their prescribed medications.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MONTERA, THE	FACILITY NUMBER: 374604083
	VISIT DATE: 06/02/2023

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[CONTINUED FROM LIC 809]

Staff interview and records revealed: On 01/13/2023, R1 received two (2) medications for treatment of Parkinson’s Disease and one (1) medication for treatment cholesterol, none of which were prescribed to them. Licensee’s staff timely notified R1’s physician and responsible party of the incident, and increased observation of R1 over the next three days. Licensee coordinated with the pharmacy to replace the medications for the other resident (who these medications were assigned to) and ensured that the other resident received them correctly. Upon discovery of the error, Licensee immediately removed S1 from medication pass duties, then formally retrained them (to include skills testing) before reinstating them in such tasks.

Staff interview and records further revealed: On 02/10/2023, R2 received multiple medications which indeed belonged to them, but were given to them at the wrong time of day. Licensee’s staff timely notified R2’s physician and responsible party of the incident, and increased observation of R2 over the next three days. Upon discovery of the error, Licensee immediately removed S2 from medication pass duties, then formally retrained them (to include skills testing) before reinstating them in such tasks.

A preponderance of evidence exists showing that in the context of the above incidents, Licensee did not give R1 and R2 their respective medications as they were prescribed. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Turner, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/02/2023 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MONTERA, THE	FACILITY NUMBER: 374604083
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/02/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	As of the date of deficiency issuance, S1 and S2 are no longer employed at the facility. Per staff interview / employee records: upon discovery of the each medication error incident, the staff involved were immediately removed from med pass duties and retrained (to include skills validation/testing) before being reinstated in medication tasks. Licensee also conducted retraining for its larger med tech team following each incident. These actions resolve the deficiency.
	8 9 10 11 12 13 14	Based on records and interviews, the licensee did not assist 2 of 190 residents (R1 and R2) with self-administered medications as needed/prescribed, which posed a potential health risk to persons 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.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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