<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 10/23/2023
Date Signed: 10/25/2023 06:45:47 AM

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
10/27/2020 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20201027100955
FACILITY NAME:MONTERA, THEFACILITY NUMBER:
374604083
ADMINISTRATOR:JUDITH PIERFAXFACILITY TYPE:
740
ADDRESS:5740 LAKE MURRAY BLVDTELEPHONE:
(619) 832-2599
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:225CENSUS: 190DATE:
10/23/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Executive Director (ED) Emily TurnerTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's care plan is not being followed.
Resident is not adequately supervised resulting in falls and injuries.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegations. LPA was met and granted entry into the facility by Executive Director (ED) Emily Tuner identified herself, and informed ED Tuner of the purpose for the visit.

The Department’s investigation consisted of facility and resident records reviews, as well as outside source, staff, and resident interviews.

It was alleged that staff are not following Resident care plan. A review of Resident’s 1 (R1’s) records revealed R1 was August 14, 2020, with a primary diagnosis of mild dementia, was non-ambulatory, and required physical assistance while ambulating. A review of facility records revealed at the time of admission R1 was a total assist for ambulation and was to be assisted by a staff member to escort to and from activities, meals, etc., R1 was also assigned stand-by assistance while they conducted transfers. An interview with an Outside Source (OS1) revealed R1 had sustained 3 falls before discharging from the facility on November 4,2020.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023
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 5
Control Number 08-AS-20201027100955
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: 10/23/2023
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
A facility records review corroborated R1’s falls and indicated two of the 3 falls were unwitnessed. Records also revealed at least one of the falls occurred while R1 was ambulating throughout the facility with no care staff present to provide assistance with ambulating as documented in R1's care plan.

It was also alleged R1 was not adequately supervised resulting in falls and injuries. A facility records review revealed on September 27, 2020, R1 was found on their bedroom floor after sustaining a fall, records also revealed R1 sustained 2 more falls, one on October 23, 2020, when R1 was using a walker while walking throughout the facility unassisted by staff, and another fall on October 25, 2020. An outside source interview and outside source records review confirmed R1 was taken to the Doctor after their fall on October 23, 2020, and a skin tear/abrasion was found on the back of R1’s elbow. Facility records revealed R1 had a body check after sustaining the fall on October 23rd and no injuries were observed. Records also revealed R1 was supposed to be assisted by a staff member while ambulating and/or have a stand-by staff member present to assist with transfers, both to prevent falls.

Based on interviews and records reviews the above allegations were substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is being cited on the attached LIC 9099-D.

An exit interview was conducted with, Appeal Rights (LIC 9098 01/16) along with a copy of this report was provided to ED Turner and their signature on this form confirms receipt of these rights.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20201027100955
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: 10/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2023
Section Cited
CCR
87464(c)
1
2
3
4
5
6
7
The admission agreement shall specify which of the basic services are desired and/or needed by, and will be provided for, each resident per level of care as defined in the admission agreement.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
ED Turner provided proof of on-going trainings for care staff in regard to residents care plan derived from an assessment as stated in the admission agreement.
8
9
10
11
12
13
14
Based on interviews and records reviews staff did not follow R1's admission agreement. This posed an potential health and safety risk for 1 out of 145 residents in care.
8
9
10
11
12
13
14
Type B
11/23/2023
Section Cited
CCR
87464(f)(c)
1
2
3
4
5
6
7
Basic services shall... the facility assumes responsibility for...,ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered...

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
ED Turner provided proof of on-going training for care staff in regard to proper care for residents deemed as fall risks.
8
9
10
11
12
13
14
Based on interviews and record reviews staff did not ensure R1 was assisted during ambulating to prevent potential falls.

This posed a potential safety risk to 1 out of 145 residents 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.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/27/2020 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20201027100955

FACILITY NAME:MONTERA, THEFACILITY NUMBER:
374604083
ADMINISTRATOR:JUDITH PIERFAXFACILITY TYPE:
740
ADDRESS:5740 LAKE MURRAY BLVDTELEPHONE:
(619) 832-2599
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:225CENSUS: 190DATE:
10/23/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:ED Emily TurnerTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was handled in a rough manner.
Resident's call button is not responded to.
Resident's authorized representative was not informed of incidents involving resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegations. LPA was met and granted entry into the facility by ED Turner, identified herself, and informed ED Turner of the purpose for the visit.

The Department’s investigation consisted of facility and resident records reviews, as well as outside source, staff, and resident interviews.

It was alleged that staff handled Resident 1 (R1) in a rough manner on October 17, 2020. An interview with an Outside Source (OS1) reveal R1’s attending Staff 1 (S1) was aggressive while trying to assist R1 with dressing, however the name of S1 was unknown. A facility records review revealed no progress notes regarding R1 on the day of the alleged incident. An interview with facility Staff 2 (S2) revealed no information regarding the incident was able to be obtained to corroborate the allegation, and several staff interviews conducted with residents in care revealed no negative experience with facility staff during the time of the alleged accusation.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
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 5
Control Number 08-AS-20201027100955
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: 10/23/2023
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
It was also alleged facility staff did not respond to R1’s pendant calls. An interview with an Outside Source 1 (OS1) revealed R1 had pressed their pendant for assistance but staff were not responding. An interview with facility staff revealed residents are provided pendants that will alert staff when seeking a caregiver for assistance by either pressing a button or using a pull cord. A facility records review revealed R1’s pendant needed a new battery and maintenance staff had attended to and resolved the issue on that same day.

Lastly, it was alleged R1’s Responsible Party (RP) was not informed of incidents involving R1. A facility records review revealed facility staff were in consistent communication with R1’s RP. Records reviews also revealed notifying the RP of incidents within the mandated reporting requirement time frame. Interviews conducted with residents in care and outside sources yielded no information that corroborated the accusation.

Based on interviews conducted and pertinent records reviewed, it was determined the above allegations were unsubstantiated. An unsubstantiated finding means that although the allegations may have happened or is valid, there was not a preponderance of evidence to prove that the alleged violations occurred.

An exit interview was conducted with ED Turner and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) will be provided to ED Turner. Signature on this report confirms receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5