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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 06/19/2023
Date Signed: 06/19/2023 03:56:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/17/2023 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20230117161601
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: 189DATE:
06/19/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Memory Care Director Aileen SpenceTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not meet residents' needs
Facility was not kept clean
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow-up and deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Memory Care Director Aileen Spence.

During today's visit, LPA observed residents in care and interviewed staff.

The Department’s investigation consisted of interviews with staff, residents, and outside sources, records review, and a tour of the facility. It was alleged that staff did not meet residents’ needs and the facility was not kept clean. Interviews and review of medical records revealed that Resident 1 (R1) required assistance with incontinence care, used incontinence briefs, and was unable to care for grooming, bathing, dressing, or toileting independently. Review of records and interviews revealed that R1 required between 12 and 24 safety checks by staff a day.
Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
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 6
Control Number 08-AS-20230117161601
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/19/2023
NARRATIVE
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Interviews revealed that R1 shared a room with Resident 2 (R2) who employed private caregivers who provided R2 with companionship and were present in the shared room for about 20 hours a day. Interviews with facility staff revealed that staff are tasked with checking on residents who require assistance with incontinence care every 2 hours. Interviews revealed that facility staff were aware that R2’s private caregivers were not responsible for providing any care for R1 or providing any housekeeping or cleaning of the shared room. Interviews revealed that facility staff did not conduct safety checks on R1 resulting in R1 sitting in soiled incontinence briefs. Interviews revealed that on at least one occasion, R1 had soiled an incontinence brief resulting in a urine odor which originated from a fabric chair. Interviews revealed that on at least one occasion, there was feces on the floor of R1’s room and it was not cleaned for several hours and after multiple requests for staff to clean the room. Interviews revealed that R2’s private caregivers would change dirty sheets, clean the shared room, and provide incontinence care for R1.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has been met, therefore, these allegations are deemed substantiated. The following deficiencies are cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Memory Care Director Aileen Spence, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20230117161601
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2023
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontience (b)(3) Ensuring that incontinent residents are kept clean and dry and the facility remains free of odors from incontinence. This requirement has not been met as evidenced by:
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Memory Care Director stated she will conduct inservice with staff regarding incontinence care and will submit inservice sign-in sheet to LPA by POC due date.
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Based on interviews and records review, the Licensee did not ensure that R1 was kept clean and dry. This poses a potential health risk to 189 of 189 residents in care.
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Type B
07/05/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) the facility shall be clean, safe, and sanitary at all times... This requirement has not been met as evidenced by:
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Memory Care Director stated she will conduct inservice with staff regarding sanitation and will submit inservice sign-in sheet to LPA by POC due date.
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Based on interviews and records review, the Licensee did not ensure that the facility was kept clean. This poses a potential health risk to 189 of 189 residents 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/17/2023 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20230117161601

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: 189DATE:
06/19/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Memory Care Director Aileen SpenceTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Licensee did not observe a resident’s change in condition
Licensee did not provide hygiene items
Licensee did not provide documents to responsible party
Lack of supervision resulting in a resident sustaining an injury

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow-up and deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Memory Care Director Aileen Spence.

During today's visit, LPA observed residents in care and interviewed staff.

The Department’s investigation consisted of interviews with staff, residents, and outside sources, records review, and a tour of the facility. It was alleged that a lack of supervision resulted in a resident sustaining an injury. Records review revealed that in December 2022, Resident 1 (R1) attempted to enter Resident 2’s (R2) room while R2 was in the room. R2 attempted to prevent R1 from entering the room and pushed the door back which resulted in both residents falling and sustaining injuries.

Continued on LIC9099-C page...
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20230117161601
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/19/2023
NARRATIVE
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Interviews revealed that staff heard both residents yelling and when they arrived at R2’s room, both residents were on the floor. Staff notified the med tech who contacted 911 and law enforcement. Paramedics arrived, assessed both residents, and R2 was transported to the hospital for care while R1 refused transportation. Interviews revealed that law enforcement provided the facility staff with a case number for the incident. Interviews revealed that when asked about the incident, R1 believed they were entering their room and R2 stated that they yelled at R1 to go away and pushed on the door to stop R1 from entering. Records review revealed that R1 had a diagnosis of dementia, hallucinations, visual impairment, and had a history of wandering at night. Records review revealed that R1 had been reassessed for additional care levels multiple times between 2020 and 2023 and did not have any additional status checks. Interviews revealed that staff would attempt to keep R1 in common areas and would check on R1 if they were not in view of staff. Interviews revealed that staff would conduct 2-hour checks on residents who remained in their rooms and residents who required assistance with toileting. Interviews revealed that the incident occurred approximately 1 hour after the scheduled check. Interviews were unable to confirm when the last time staff observed either R1 or R2. Record review revealed that R2 had a diagnosis of mild cognitive impairment and was a fall risk. Interviews did not reveal any prior altercations or incidents between R1 and R2.

It was alleged that the Licensee did not observe a resident’s change in condition. Interviews and records review revealed that Resident 3 (R3) had a diagnosis of dementia, had a history of anxiety and agitation, and required assistance with incontinence care, bathing, dressing, and eating. Interviews and records review revealed that R3 was reassessed in July 2022 which showed that R3’s had slightly declined and R3’s needs had increased. Interviews revealed that the facility staff encouraged residents, including R3, to remain in common areas and participate in activities. Interviews revealed that R3 enjoyed participating in activities and R3’s agitation had decreased. Interviews did not reveal any concerns regarding the staff not observing R3’s decline.

Continued on LIC9099-C page...
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20230117161601
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/19/2023
NARRATIVE
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It was alleged that the Licensee did not provide hygiene items. Review of the facility’s admission agreement revealed that the facility did not provide any health care items for outside services including, but not limited to home health, hospice, medical supplies, medications, and incontinence products. Additionally, the admission agreement stated that supplies for personal care and hygiene are not included in the basic fee, and would be provided by the facility at an additional fee. Record review revealed that the admission agreements for R2 and R3 declined the purchase of personal hygiene supplies. Interviews revealed that staff had a surplus supply of hygiene items and would provide them to residents when necessary and would notify the resident’s responsible party of the need for additional hygiene items.

It was alleged that the licensee did not provide documents to a responsible party. Interviews revealed that if an individual requested information or documentation on a resident, staff would ensure that the requesting individual was the power of attorney (POA) for the requested information and would provide the requested information. If that individual was not the POA, staff would either inform the individual to request information on the resident from the POA or would offer to contact the POA with the individual to request permission to provide the information. Interviews revealed that law enforcement did not provide the facility with any documents during calls and would only provide a case number for reference. Interviews revealed that staff would provide the case number to resident’s POA when requested.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

An exit interview was conducted with Memory Care Director Aileen Spence, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16)
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6