374604083-8-28-2023-08-AS-ADOO-CV5SYA-20230828141714

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604083
Report Date: 05/15/2023
Date Signed: 08/28/2023 02:18:01 PM

Document Has Been Signed on 08/28/2023 02:18 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
SAN DIEGO RO, 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:	6198322599
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	225	CENSUS: 188	DATE:	05/15/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:48 AM
MET WITH:	Emily Turner Executive Director		TIME COMPLETED:	02:00 PM

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

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

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (RO) on 04-25-2023. Per the LIC624: On 04-25-2023 at around 2:30 PM, Resident #1 (R1), who lives in the facility’s secured memory care neighborhood, was briefly AWOL (absent without leave). [See LIC811 Confidential Names List for a description of person identifiers used in this report.] Staff #1 (S1), received a call from a Neighbor #1 (N1) to inform the facility that Resident #1 (R1) was with her at her front lawn and R1 requested to return to the facility. Staff #2 (S2) along with Staff #3 (S3) walked across the street and escorted R1 back to the memory care neighborhood. R1 was unharmed/uninjured.

During today’s visit, LPA briefly toured the facility and performed a welfare check, verifying that R1 was indeed unharmed/uninjured. LPA also tested the delayed egress exit doors associated with the facility’s memory care neighborhood, and verified their alarms were all operational. LPA also collected copies of pertinent administrative, care, and medical records, and interviewed relevant staff.

According to R1’s latest LIC602 Physician’s Report, dated 12-15-2022, R1 was diagnosed with “Alzheimer’s Dementia unspecified severity.” R1’s doctor determined that R1 was not able to safely leave the facility unassisted. Per R1’s LIC603 Pre-Placement Appraisal, dated 01-11-2022, R1’s short-term memory was “poor” due to Alzheimer’s Dementia.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: 05/15/2023

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 LIC 809]

Staff interview revealed: leading up to the incident, Family Member #1 (F1) briefly disarmed and opened an egress door while moving belongings out of the memory care neighborhood. This allowed R1 to follow F1 out of the memory care neighborhood and go into the main lobby. Not recognizing that R1 was a memory care resident, Staff #1 (S1) allowed R1 to follow the visitor out. It was S1’s fourth month working in their job position, which was centered in the lobby.

A preponderance of evidence exists to show that preceding the incident, Staff allowed Family Members to utilize the Key/FOB to disarm and open the egress door. Facility staff did not equip S1 the knowledge and/or training they needed to visually recognize R1 as a memory care resident, which contributed to R1’s AWOL.

Following the incident, licensee conducted an internal investigation, placed photos of its memory care residents in a confidential binder available for lobby staff to review and reference, R1 has been equipped with a wanderguard alarm. On 04-25-2023 all staff was notified that under no circumstance are any vendors or family members be given the FOG/Key to the Memory Care Neighborhood and only facility staff can allow entrance and exit to the Memory Care Neighborhood. On 05-04-2023 Licensee conducted a missing resident drill and training for its staff.

One 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 Emily Turner. A hard copy of this report, the LIC809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to licensee during today’s visit.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/28/2023 02:18 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
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: 05/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/15/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General: "(a) Facility personnel shall at all times be .. competent to provide the services necessary to meet resident needs." This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Licensee placed photos of its memory care residents ina confidential binder available for the lobby staff to review and reference. On 04/25/2023 all staff was notified that only facility staff may allow entance and exit to the Memory Care. On 05/04/2023 Licensee conducted a drill and retrainig for its staff on the topic of missing residents.
	8 9 10 11 12 13 14	Based on interview, the licensee did not ensure facility personnel was competent to provide the services necessary to meet the needs of 1 of 188 residents (R1), which posed a potential safety risk to persons in care.	8 9 10 11 12 13 14	Licensee agreed to add a sign to the inside of the Memory Care egress door.
	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: John Rante	TELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3