374604083-7-16-2025-08-AS-JROO-DL5V7L-20250902161119

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 07/16/2025
Date Signed: 07/16/2025 05:15:06 PM

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
01/10/2025 and conducted by Evaluator Arian Golbakhsh

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20250110153230

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: 180	DATE:	07/16/2025
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Associate Executive Director Aileen Spence		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Neglect to resident resulting in serious bodily injury.
Staff did not assist resident with administration of medication as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit with Associate Executive Director Aileen Spence.

On 01/15/2025, it was alleged that a resident (identified as R1) suffered neglect resulting in serious bodily injury. Per the complaint, it was alleged that a caregiver dropped R1 while transferring them, resulting in rib fractures. The complaint also alleged that staff were not administering medication to R1 as prescribed. The Department’s investigation consisted of unannounced facility visits, records review, and interviews with staff, residents, and outside sources.

R1 was a resident at the secured Memory Care unit in the facility with a diagnosis of Mild Cognitive Impairment (MCI) and was an identified fall risk. Per R1’s facility assessment, they required a one (1) person total assist or wheelchair escort to activities and meals. R1 also required total/significant assistance with medication administration, per their Physician’s Report. [Continued on LIC 9099C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250110153230

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: 07/16/2025

NARRATIVE

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[Continued from LIC 9099]

Regarding the allegation of neglect resulting in serious bodily injury, R1 has a documented history of health conditions that increases risk of fractures and bone weakness. Interviews with outside source medical professionals reveal the rib injuries sustained by R1 (imaging conducted August 16th, 2024) were age indeterminate, meaning it was difficult to determine when they occurred. R1 was also a known fall risk, but staff interviews and file review of R1's records reveal staff were aware and took precautions to prevent and/or mitigate fall risk. Per staff interviews, R1 did not have any falls around the time alleged in the complaint (August 2024) nor did any staff interviewed recall R1 having any falls or being dropped during assisted transfers. File review of R1’s charting records during that time corroborate that there were no documented falls either. Interviews conducted with the staff fitting the description indicated in the allegation revealed that R1 was not assigned to those staff members for care and/or transfers. Interviews with residents indicated no concerns regarding their care and staff supervision.

Regarding the allegation of medications not being administered as prescribed, file review and interviews with staff and outside sources reveal that R1 requires routine breathing treatments for a health condition. File review of facility records indicate that R1’s treatments were given routinely from July 2024 through January 2025 with no issues. Staff interviews revealed procedures taken when administering this specific type of treatment (staying with resident for duration of treatment) as interviews revealed that residents will often try to remove equipment necessary for treatment. Multiple staff members interviewed recalled resident R1 and having to stay with them and supervise during treatments. Staff interviews revealed that that they felt there were enough staff to timely give out medications, however one (1) indicated that they felt they needed more staffing in the Assisted Living unit as there are more residents residing there. Interviews with residents and outside sources raised no concerns about medications or residents’ care. Resident interviews indicated they received their medications timely. Additionally, interviews with outside sources revealed that the facility notifies them of incidents or updates regarding their respective residents.

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 Associate Executive Director Spence 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: 07/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025

LIC9099 (FAS) - (06/04)

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