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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 06/23/2025
Date Signed: 06/23/2025 05:40:55 PM

Substantiated


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
02/10/2025 and conducted by Evaluator Arian Golbakhsh
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20250210130613
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: 76DATE:
06/23/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Health Services Director Robin Mendez and Executive Director Cathy AllenTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Resident in care developed an infection due to staff neglect.
Staff did not report a resident's change in condition to resident's Responsible Party as necessary.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to conduct a complaint investigation and delivered findings regarding the above mentioned allegations. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit to Health Services Director Robin Mendez and Executive Director Cathy Allen. Note, LPA did step out for lunch from 12:50-1:50pm.

On 02/10/2025, the Department received a complaint where it was alleged that the facility did not notify a resident's (identified as R1) Responsible Party as necessary following an injury R1 sustained which later became infected. The Department’s investigation consisted of unannounced facility visits, records review, and interviews with staff and outside sources.

[Continued on LIC 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
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 5
Control Number 08-AS-20250210130613
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: 06/23/2025
NARRATIVE
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[Continued from LIC 9099]

Interviews with staff and outside sources reveal that R1's Responsible Party was initially informed of an injury sustained by R1. File review also corroborated documentation of that notification, however no record of further updates to R1's responsible party were noted. File review notes basic first aid being administered for a period of two (2) days after initial injury and then nothing for twelve (12) days until a note regarding new medication orders for a developed infection, after R1 was taken by their Responsible Party to receive medical attention for the injury. Staff interviews reveal that basic dressing changes were conducted every other day but no wound care arrangements were ever set up, nor arrangement for appropriate medical care.

Based on LPA's review of records, interviews with staff and outside sources, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited per California Code of Regulations, Title 22, Division 6 on the attached 9099D. An exit interview was conducted with Health Services Director Mendez to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20250210130613
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/11/2025
Section Cited
CCR
87465(a)(1)
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87465 (a)(1): The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirment was not met as evidenced by:
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Licensee will conduct review and/or retraining with care staff on wounds and changes in condition and submit proof to LPA by POC due date.
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Based on file review and interviews, the Licensee did not arrange or assist in arrangement of wound care for R1, resulting in an infection, posing a potential health and safety risk to 1 out of 76 residents in care.
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Type B
07/11/2025
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning [. . . ] licensee shall ensure that such changes are documented and brought to the attention of [. . .] the resident's responsible person, if any.
This requirement is not met as evidenced by:
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Licensee will conduct review and/or retraining with care staff on wounds and reporting changes in condition and submit proof to LPA by POC due date.
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Based on file review and interviews, the licensee did not report to R1's responsible party of R1's change in condition of a worsening wound, posing a potential health and safety risk to 1 out of 76 residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
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
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
02/10/2025 and conducted by Evaluator Arian Golbakhsh
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20250210130613

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: 76DATE:
06/23/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Health Services Director Robin Mendez and Executive Director Cathy AllenTIME COMPLETED:
05:45 PM
ALLEGATION(S):
1
2
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5
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8
9
Food services are inadequate.
Staff do not ensure that residents incontinence care needs are being met.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to conduct a complaint investigation and delivered findings regarding the above mentioned allegations. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit to Health Services Director Robin Mendez and Executive Director Cathy Allen. Note, LPA did step out for lunch from 12:50-1:50pm.

On 02/10/2025, the Department received a complaint where it was alleged that food services provided by the facility did not meet resident needs and that staff do not ensure incontinence needs of residents are met. The Department’s investigation consisted of unannounced facility visits, records review, and interviews with staff, residents, and outside sources.

[Continued on LIC 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
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-20250210130613
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: 06/23/2025
NARRATIVE
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[Continued from LIC 9099]

Regarding food services offered by the facility, file review, and interviews with residents, and outside sources all support that food options provided were varied. Staff interviewed revealed that any residents that required assistance with feeding have meals brought to their room for 1:1 assistance, and residents present in the dining rooms were determined to be able to eat on their own.

Regarding the allegation of lack of staff not ensuring residents' incontinence care needs are being met, interviews with outside sources revealed no concerns regarding staff ability to meet resident needs. Residents interviewed corroborated that staff assist with toileting when needed and shared no concerns regarding timeliness of staff aid. Staff interviews also reveal that there are "floater" staff in each building that assist where needed for coverage.

Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred – therefore the allegations have been determined to be UNSUBSTANTIATED. An exit interview was conducted with Health Services Director Mendez to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5