374604083-3-24-2025-08-AS-SJAB-DF4R4N-20250325124150

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 03/18/2025
Date Signed: 03/24/2025 10:17:36 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
12/17/2024 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20241217094614

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: 185	DATE:	03/18/2025
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Aileen Spence Associate Executive Director		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff are not ensuring that facility is maintained according to infection control requirements.
Facility staff are not ensuring separation of residents whose illness requires separation.

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

On December 17, 2024, it was alleged that the facility staff are not ensuring facility is maintained according to infection control requirements. The Department’s investigation consisted of unannounced facility visit, interviews with facility staff, outside sources, and records review.

Staff interviews revealed that the facility did have an infectious outbreak. The outbreak was reported to CCLD on December 10, 2024, with ten (10) residents at the Memory Care Unit with symptoms of vomiting and diarrhea starting on December 9, 2024.

(Continued on LIC9099 p.2)

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-20241217094614

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)

The Montera Infection Control Plan states there should be a Post “Infection Outbreak” signs on the outside of the community to notify visitors of the outbreak. During an interview Staff 1 (S1) confirmed there were no sign posted “Infectious Outbreak” outside the community to notify visitors of the outbreak as per the facility infection control plan.

Staff 2 (S2) was interviewed and confirmed there were no sign posted “Infectious Outbreak” outside the community to notify visitors of the outbreak as per the facility infection control plan.

Staff 3 (S3) was interviewed and confirmed there were no sign posted “Infectious Outbreak” outside the community to notify visitors of the outbreak as per the facility infection control plan.

Outside source 1 (OS1) while visiting the memory unit observed two (2) residents that needed assistance with both hygiene needs and environmental cleaning needs. OS1 stated staff claimed there was only one (1) housekeeper for both buildings. OS1 stated on December 10, 2024, while in the activity room, staff was overheard stating that multiple residents had Gastrointestinal (GI) symptoms. The facility did not notify OS1 of the GI illness. There were no signs posted that alerted the visitors of an infectious illness.

Review of facility records revealed that housekeeping staffing hours were documented on a daily basis. The hours of housekeeping varied on weekdays and weekends. Staff 3 (S3) was interviewed and they stated the care giving staff would assist with environmental cleaning as needed. S3 stated they were in the process of hiring more staff.

S1 was interviewed and verified that housekeeping and care giving staff both assisted with environmental cleaning as needed. The records reviewed revealed adjustments were made with the housekeeping schedule to maintain the facility cleanliness as needed.

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-20241217094614

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 3 of 3)

A review of the facility infection control plan state staff members to be in serviced on the signs and symptoms of GI illness, modes of transportation, staff procedures to prevent the spread of infection, and reporting protocols. Review of facility records revealed there were staff in services of signs and symptoms of illness, modes of transmission and staff procedures to prevent the spread of infection.

The facility infection control policy states there should not be any new admissions during the infectious illness. Records reviewed showed two (2) admissions within 3 days of reporting the infectious illness started.

On December 17, 2024, it was alleged facility staff are not ensuring separation of residents whose illness requires separation. Interview with S1 revealed that the residents in the memory care unit were not separated from the other residents who exhibited infectious illness because of their memory deficits the residents were unable to isolate in their rooms.

Staff 2 (S2) and Staff 3 (S3) confirmed during an interview that the residents were not separated during the infectious illness. The memory unit has residents who do not remember how to isolate in their rooms and are unable to retain directions and are forgetful due to dementia.

OS1 and Outside source 2 (OS2) stated they observed residents who were exhibiting signs and symptoms of infectious illness sitting next to residents without signs or symptoms of infectious illness.

The Department investigated the above allegations, and the preponderance of the evidence standard was met. Therefore, the above allegations are substantiated. Deficiencies were cited in accordance with the California Code of Regulations, Title 22 and is documented on the attached 9099-D. An exit interview was conducted with Executive Director (NAME) and a plan of correction was jointly developed. 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: 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: 4 of 4

Control Number 08-AS-20241217094614

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 8470(2)(A)	1 2 3 4 5 6 7	Infection Control (2) Environmental cleaning.. disinfection activities shall be performed.. (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material.	1 2 3 4 5 6 7	The Licensee agrees to schedule an in servicel training regarding infectin control with 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 evidenced by: Based on records review and interviews, licensee did not accord safe, healthful accommodations to 2 out of 120 residents. This posed a potiential health risks to persons in care.	8 9 10 11 12 13 14
Type B 04/18/2025 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations…” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	The Licensee agrees to schedule an in servicel training regarding resident rights with 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	Based on records review and interviews, licensee did not accord safe, healthful comfortable accommodations to 2 out of 120 residents. This posed a potiential personal rights risks to persons in care.	8 9 10 11 12 13 14

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)

Page: 3 of 4