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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 06/12/2025
Date Signed: 06/17/2025 04:28:00 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
10/26/2022 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20221026094925
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: DATE:
06/12/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Cathy Allen Executive DirectorTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Sexual Abuse
The staff are not assisting the resident with feeding
Staff are mismanaging the residents' medication
The Resident's bed did not have a mattress cover
The resident's bed did not have complete sheets
Staff did not follow the residents' dietary requests
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Cathy Allen, Executive Director.

The Department’s investigation consisted of interviews with staff and outside sources, and records review of relevant documents pertinent to this investigation.

On October 26, 2022, Community Care Licensing (CCL) received a complaint with the following allegation(s): Sexual Abuse, Staff are not assisting resident with feeding, Staff are mismanaging resident's medication, Residents bed did not have a mattress cover, Resident's bed did not have complete sheets and lastly, Staff did not follow residents’ dietary request.

(Continued on LIC9099 1 of 3)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
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 3
Control Number 08-AS-20221026094925
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: 06/12/2025
NARRATIVE
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(Continued from LIC9099 2 of 3)

It was alleged that staff sexually abused Resident 1 (R1). Review of R1’s medical assessment and appraisal documents dated July 22, 2022, revealed R1 has a history of forgetting words, disorientation, confusion, hallucinations, and nightmares. R1 can fluctuate from being non-verbal and non-ambulatory to verbal and ambulatory. There are days when R1 can communicate their needs and days when they cannot.
Interviews with staff, outside sources and review of admission records revealed R1 was admitted to the facility on August 6, 2022, and occupied a single room at the memory care portion of the facility. Interviews with staff revealed R1 was mostly non-verbal, non-ambulatory, with hallucinations and confusion. The staff stated that R1 has not stated that anyone sexually assaulted them. Review of progress notes and interviews with staff and outside sources denied having reports from R1 regarding abuse. Interviews with staff, outside sources, and review documents received by the Department from the facility on 10/25/2022 revealed that R1 reported to Outside source 1 (OS1) that they were sexually abused by a staff member in the shower. R1 was not able to recall the dates or times the incident happened. OS1 reported the incident to the facility staff. The facility staff completed a body check, and there were no signs of abuse. R1 did not repeat the alleged occurrence when asked by outside sources or staff. Review of documents received by the Department revealed that facility management followed reporting requirements and submitted an incident report and report of suspected elder abuse to the Department on October 26, 2022, as well as notified R1’s responsible parties.

It was alleged that staff are mismanaging the residents' medication. Review of records revealed that there has not been any medication mismanagement. Staff interviewed and there has not been any medication mismanagement. Outside source 1 (OS1) stated that there have not been any medication mismanagement.
It was alleged that R1’s bed did have a mattress cover. LPA observed five (5) bedrooms, including R1’s bedroom. All five beds contained a mattress cover. All five (5) bedrooms have the appropriate bedding, lighting, closet space, and blankets. The rooms were not cluttered, and there were no foul odors.
It was alleged that R1’s bed did have complete sheets. LPA observed five (5) bedrooms, including R1’s bedroom. All five beds contained complete sheets. All five (5) bedrooms have the appropriate bedding, lighting, closet space, and blankets. The rooms were not cluttered, and there were no foul odors.
Lastly, it was alleged that the licensee is not meeting R3’s dietary needs as they require chopped food, and they are a vegetarian. Interviews with residents revealed that if they need a special diet, the facility will accommodate their needs or special requests. Interview with staff established that R1 was provided with their specific dietary needs. An interview with an outside source established that there have been no issues
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20221026094925
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: 06/12/2025
NARRATIVE
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Continued from LIC9099C 3 of 3

observed with residents’ food accommodations. Records review showed that R1’s dietary needs were documented and staff followed R1’s dietary needs.

Based on LPA's interviews and record reviews, there is no preponderance of evidence to prove that the alleged violation occurred; therefore, the allegations are unsubstantiated. An exit interview was conducted with the Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3