374604083-7-11-2025-08-AS-SJAB-DJNNUW-20250717104659

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 07/08/2025
Date Signed: 07/11/2025 10:22:38 AM

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
03/25/2025 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20250325121535

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: 183	DATE:	07/08/2025
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Gerrit Hoevers Director of Environment Service		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Questionable Death
Facility staff are not coordinating hospice services appropriately to ensure resident safety

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 the Executive Director.

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

On March 25, 2025, Community Care Licensing (CCL) received a complaint alleging a questionable death, and the Facility staff are not coordinating hospice services appropriately to ensure resident safety.

(Continue on LIC9000C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025

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-20250325121535

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: 07/08/2025

NARRATIVE

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(Continued from LIC9099 2 of 3)

R1 had an unwitnessed fall on March 1, 2025, with no visible injuries. R1 was admitted to hospice care on March 13, 2025. R1 was prescribed Lorazepam 0.5 mg 1 tab by mouth every four (4) hours for restlessness, mood swings, and agitation. On March 14, 2025, R1's records revealed they were sleepy and lethargic. R1's new order starting March 14, 2025, was Lorazepam 0.5 mg six (6) times a day. On the morning of March 15, 2025, documents revealed that R1 was very sleepy and weak but did not sleep well and was aggressive when staff tried to help R1 lie down in bed. By midmorning on the same date, R1 was found sitting on the floor with a raised hematoma to the back top of their head and a small skin tear to the right cheek. R1 was sent to the hospital for further evaluation. R1 returned to the facility on the same day. R1's Lorazepam was discontinued, and hospice was notified of R1's return to the facility. The diagnosis upon R1's return was a Subdural hematoma with Subarachnoid bleed. On March 16, 2025, during the evening hours, R1 was unresponsive to touch and voice. On March 17, 2025, R1 had a change of condition with labored breathing. On March 19, 2025, R1 was given Lorazepam 2 mg every 15 minutes for 3 doses until seizures stop. On March 20, 2025, R1 passed away.

Records reviewed revealed that upon admission to the facility on February 13, 2023, R1 was able to transfer themselves, feed themselves, and socialize well with other residents. The following year, the Physician's report on April 15, 2024, documented that R1's dementia had progressed, and R1 needed more assistance, and they were more restless with mood swings and agitation during the evening hours. The Physician's report also had an additional notation of having a fall without fracture. On February 6, 2025, a resident assessment assessed R1 at a level 4. R1 required additional support due to multiple behavioral interventions. There were no unusual incident reports filed with the Department regarding the March 1, 2025, fall documented in the resident charting notes. There were no unusual incident reports filed with the Department for the March 15, 2025, fall. The facility addressed and documented R1's increased need for assistance. There was daily documentation by the facility staff communicating R1's changes with outside sources, the medical physician, and Hospice.

On March 25, 2025, Community Care Licensing (CCL) received a complaint alleging that the Facility staff are not coordinating hospice services appropriately to ensure resident safety.

9Continued on LIC9099 3 of 3)

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20250325121535

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: 07/08/2025

NARRATIVE

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Continued from LIC9099 3 of 3)

Outside source 1 (OS1) was interviewed and stated they did not sign the admission forms to be admitted to hospice services. OS1 also stated they did not agree upon the medication for restlessness. OS1 stated they knew R1 would not do well with the medication for restlessness. OS1 stated that the fear of using the restlessness medication was an increase in falls. OS1 stated R1 would have a higher chance of falling when taking the restlessness medication.

Outside source 2 (OS2) notified the facility and R1's medical physician that the restlessness medication was excessive and R1 was increasingly over groggy. Review of records revealed that the facility and hospice acknowledged and followed OS2 request to lower the number of times the restlessness medication was to be given.

Records reviewed revealed the facility staff and the hospice staff provided daily documentation on R1's condition and notified the medical physician of changes with R1. The medications for R1 that were adjusted for their comfort were documented on R1's daily charting, along with the hospice documentation. Staff charting and hospice charting notified OS1 and OS2 of any changes with R1.

This agency has investigated the complaint alleging the above allegations. The Department has found that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director, Cathy Allen, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025

LIC9099 (FAS) - (06/04)

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