374604083-9-26-2023-08-AS-DNGN-CW2V7J-20230926161113

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604083
Report Date: 09/26/2023
Date Signed: 09/26/2023 04:11:39 PM

Document Has Been Signed on 09/26/2023 04:11 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: 185	DATE:	09/26/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Executive Director Emily Turner		TIME COMPLETED:	04:25 PM

NARRATIVE

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LPA Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident 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 an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 06/23/2023). According to the LIC624: during the morning of 06/16/2023, an error by Staff #1 (S1) led to Resident #1 (R1) receiving doses of multiple medications which were not prescribed to them. These medications were instead prescribed to Resident #2 (R2). [See LIC 811 Confidential Names List for a description of select person identifiers used in this report].

During today’s visit, LPA performed a brief facility tour and welfare check, finding that R1 was safe and comfortable. LPA also reviewed pertinent care records and interviewed relevant staff.

According to R1’s latest LIC602 Physician’s Report (dated 04/19/2023): R1 was diagnosed with “senile degeneration of the brain” and their physician determined that they required staff assistance with storing and taking their prescribed medications. Facility manager interview corroborated this need.

Manager interview, corroborated by date and time stamped progress notes and other records, showed: During the AM shift on 06/16/2023, S1 placed the medications for R1 and R2 into two separate cups. However, S1 handed R2’s cup to R1 by mistake. By the time S1 recognized the mistake, R1 had ingested multiple of R2’s medicines. However, S1 caught their error timely enough that R2 did not ingest any of R1’s medicines. The medication errors which affected R1 during the morning of 06/16/2023 did not prevent R2 from receiving their respective prescribed medications on that date.

[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: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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: 09/26/2023

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[CONTINUED FROM LIC 809]

Licensee's staff timely notified R1’s primary care physician (PCP) and R1’s responsible person. Staff measured R1’s blood pressure every 30 minutes over the next two (2) hours, as instructed. R1’s blood pressure remained stable. Staff also increased observation of R1 over the next 48 hours. R1 did not develop any adverse symptoms. After the incident, Licensee removed S1 from medication pass duties (and has not reinstated them since). Licensee also arranged for the facility’s medication technicians at large to be retrained on accurate medication pass procedures.

A preponderance of evidence exists to show: During the incident in question, License’s staff (S1) did not give R1 medications as they were prescribed. The incident did not result in injury or illness to R1. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D).

Since the deficiency is a repeat violation within a 12-month period of time, a civil penalty of $250.00 was also assessed (refer to the LIC 421-FC). A Plan of Correction was jointly developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding reporting requirements.

An exit interview was conducted with Turner, to whom a copy of this report, the LIC 809-D, the LIC421-FC, the LIC9102-TV, 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: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/26/2023 04:11 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: 09/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/26/2023 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	Per manager interview and training records: Following the incident, S1 was removed from medication pass duties (and has not been reinstated since). On 06/22/2023, Licensee conducted a retraining of relevant staff on accurate medication pass procedures. This action resolves the deficiency.
	8 9 10 11 12 13 14	Based on records and interviews, the licensee did not assist 1 of 185 residents (R1) 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: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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