374604083-7-11-2025-08-AS-SJAB-DJPLUU-20250718090427

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 07/10/2025
Date Signed: 07/11/2025 08:37:44 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
03/11/2025 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20250311100124

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: 173	DATE:	07/10/2025
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Cathy Allen Executive Director		TIME COMPLETED:	03:28 PM

ALLEGATION(S):

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Due to staff neglect, resident has developed pressure injuries
Staff do not allow visitors privacy when visiting with resident
Staff are not following resident's special diet

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 that due to staff neglect, the resident has developed pressure injuries.

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.

(Continued on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025

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-20250311100124

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: 07/10/2025

NARRATIVE

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(Continued from LIC9099 2 of 3)

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.

On December 27, 2024, a complaint was received alleging staff do not allow visitors privacy when visiting with resident. 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.

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.

(Continued on LIC9099 3 of 3)

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20250311100124

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: 07/10/2025

NARRATIVE

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(Continued from LIC9099 3 0f 3)

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

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.
It was alleged that staff are not following the resident's special diet. Review of resident 1’s (R1) medical records revealed that R1 requires food cut, chopped, pureed, or otherwise prepared. R1 requires staff assistance with all activities of daily living, including eating meals, bathing, dressing, and toileting.

Record review revealed that R1’s medical condition has declined, and R1 is currently under hospice care. Interviews and record review revealed that R1 had declined in meal intake care and had poor meal intake while under hospice care.

Interviews and records review did not support any evidence that staff are not following the resident's special diet. Interviews with an outside source revealed they have not had any issues with the facility or with the meals/foods being served. Interviews with staff also revealed that some clients eat different meals depending on their preferences or dietary restrictions.

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 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: 07/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025

LIC9099 (FAS) - (06/04)

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