374604083-4-30-2025-08-AS-SJAB-DHGLYX-20250609091101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 04/30/2025
Date Signed: 04/30/2025 04:13:23 PM

Unsubstantiated

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
01/14/2025 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20250114093659

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: 174	DATE:	04/30/2025
		UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Cathy Allen Executive Director		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Questionable Death
Lack of supervision resulting in resident-on-resident altercation
Reporting requirements

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingoconducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to the Executive Director.

The Department’s investigation consisted of facility and outside records review interviews with staff, residents, and outside sources.

On January 14, 2025, Community Care Licensing (CCL) received a complaint alleging a questionable death. Lack of supervision resulting in resident-to-resident altercation and reporting requirements. During the investigation, the Department conducted interviews and reviewed facility records.

(Continue on LIC9000C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250114093659

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: 04/30/2025

NARRATIVE

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[Continued from LIC9099]

R1 was admitted to the hospital on December 2, 2024, for a laceration on their head after another resident pushed them. However, the injury did not result in any fractures or abnormalities, and R1 was fully alert and oriented following the injury. R1 was admitted to the hospital on December 6, 2024, due to having left sided weakness and facial droop. R1 was diagnosed with having a stroke as well as cardiomyopathy and arrhythmia, aside from the extensive medical history they already had. On December 9, 2024, R1 was having trouble following commands and consuming food. Due to their rapidly declining condition, it was agreed to have them return to the facility with comfort directed care under Hospice. R1 returned to the facility on December 11, 2024, and was seen daily by Hospice until they passed away on December 14, 2024. R1 had an extensive medical history, which contributed to death as listed on the death certificate. The immediate cause of death listed was Cerebral Infarction, which developed over several years with the underlying causes being Congestive Heart Failure and Hypertensive Heart Disease. All of these were illnesses that, based on their medical records, they had been struggling with for years.

It was alleged that the facility had a lack of supervision, resulting in resident-to-resident altercation. The interview with Staff 1 (S1) revealed the altercation in the activity room occurred on December 2, 2024, not November 2024, as described in the complaint. S1 explained that R1 lost their balance and attempted to grab another resident’s arm. Resident 2 (R2) pushed R1 away, causing them to fall. R1 sustained a laceration on their scalp as a result of the fall. R1 was evaluated, 911 was called, and they were transported to the Hospital where they were treated and returned to the community on the same day. There was no physical assault, as described by the reporting party in the complaint. The facility documented the incident on an LIC 624 Unusual Incident Report.

Lastly, it was alleged that the facility did not report the incident. Records show that the facility documented the incident on a LIC624 Unusual Incident Report, and the report was sent to the appropriate agency.

Based on the Department's interviews and record reviews, there is not a preponderance of evidence to prove alleged violations occurred, therefore, the allegations are unsubstantiated. A copy of this report and Appeal and Licensee Rights (LIC 9058 03/22) were provided to the facility Executive Director.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

LIC9099 (FAS) - (06/04)

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