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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604083
Report Date: 09/26/2024
Date Signed: 09/30/2024 03:42:49 PM


Document Has Been Signed on 09/30/2024 03:42 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



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: 186DATE:
09/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Sanjay Kabadi Executive Director TIME COMPLETED:
11:45 AM
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
Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Sanjay Kabadi Executive Director.

Today’s visit was in response to an incident which licensee self reported via an LIC624 Incident Report on September 25, 2024. The report described Resident #1 (R1 – See LIC811 Confidential Names List for identification of R1), to be sent to the Emergency Room at 10:00 am on September 13, 2024, by R1's Primary Care Physician for uncontrollable back pain.

LPA briefly toured the facility, performed a welfare check on residents in care, interviewed residents and staff, and obtained copies of pertinent facility records. No immediate health or safety risks were observed and no deficiencies were cited during this visit. Additional case management will be provided for this incident, including subsequent visits and staff interviews, as needed.

An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22)  were left with the Executive Director, whose signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1