374604083-7-9-2025-08-AS-APAO-DJP33B-20250717175313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 07/08/2025
Date Signed: 07/09/2025 08:10:25 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
12/27/2024 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20241227084153

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:	03:00 PM
MET WITH:	Gerrit Hoevers Director of Environment Service		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not ensure resident's wound care needs were met
Staff did not ensure incontinent resident was kept clean and dry
Staff restricted resident's visitation rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings in the above-mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Executive Director Cathy Allen.

During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents, and outside sources.

On December 27, 2024, the department received a complaint alleging staff did not ensure the resident's wound care needs were met.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

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 4

Control Number 08-AS-20241227084153

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 4))

LPA Domingo interviewed Outside Source 1 (OS1), and OS1 verified that the Resident 1 (R1) was being seen four (4) times a week or more when the open area was first observed.
OS1 reviewed the documentation available to show the days and times R1 was visited and what treatment was completed.

LPA Domingo interviewed Outside Source 2 (OS2), and they verified that R1 was being seen four (4) times a week or more when the open area was first observed.
OS1 reviewed the documentation available to show the days and times R1 was visited and what treatment was completed.

Outside Source 3 (OS3) was interviewed, and they stated that the facility and staff that cared for R1's wound care communicated any changes and provided updates regarding the progress of R1's wound care.

Records reviewed revealed the physician involved with R1's care was notified of the wound care and the progress of the wound. The records contained the type of wound care treatment and the description of the wound with each visit.

It was alleged that the facility staff are not providing incontinence care to the resident. LPA Domingo reviewed records, and there was documentation that supported staff providing incontinent care during all shifts daily.

LPA Domingo interviewed OS3, and OS3 stated that the staff are very attentive and address all needs quickly. OS3 stated that there are no care complaints.

Outside sources were interviewed, and there were no complaints regarding attending to residents with incontinence care.

(Continued on LIC9099 3 of 4)

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 08-AS-20241227084153

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 LIC9099C 3 of 4)

Staff were interviewed, and they were able to describe how they know when to provide care to residents and how they keep records of when the residents are provided incontinence care.

Residents were interviewed, and they had no concerns or complaints regarding staff addressing and assisting with incontinence care.
On December 27, 2024, a complaint was received alleging that the staff restricted residents' visitation rights. The complainant alleged that the licensee did not allow Resident 1 (R1) to visit with their family in R1's room. The complainant claimed that the resident's visitation rights were being denied without any valid reason.

LPA Domingo interviewed staff to obtain their perspective on the visitation restrictions.
The staff members stated that on December 26, 2024, at 7:22 pm, when Staff 1 (S1) was entering R1's room to administer bedtime medications. S1 observed R1's family members were digitally removing R1's bowel movement. S1 told the family members to stop immediately. S1 explained that there were no physician orders for anyone to remove bowel movements from R1. S1 observed R1 to be moaning and grimacing. S1 reported what they observed to their supervisor. When S1 requested the family members to leave the door ajar so that other staff could provide supervision for R1, the family members immediately closed the door. The appropriate care providers were made aware, and they will be sending staff to check on R1's medical condition. The staff members interviewed stated that they are aware of facility policies and procedures related to visitation rights. They did not deny the family members from visiting.

Staff 2 (S2) was interviewed, and they stated that for the safety of R1, they will be requesting the family members who were in the room to only visit R1 in the common areas. At no time did S2 deny family members' visitation for R1. S2 explained to the family members that the visitation restrictions were implemented due to the family providing care to R1 without a physician's order.

Outside source 4 (OS4) was interviewed, and they agreed that due to the family members' actions, they should only visit R1 in the common areas.

(Continued on LIC9099C 4 of 4)

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20241227084153

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 4 of 4)

Records reviewed revealed there was no physician's order to digitally remove R1's bowel movements.

This agency has investigated the complaint alleging that staff did not ensure the resident's wound care needs were met, staff are not providing incontinence care to the resident, and staff restricted the resident's visitation rights. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report, along with the Confidential Names list (LIC 811), and licensee rights (LIC 9058 03/22). Executive Director, Cathy Allen's signature on this form confirms receipt of these rights

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

LIC9099 (FAS) - (06/04)

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