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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 07/16/2025
Date Signed: 07/16/2025 05:29:09 PM

Substantiated


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
12/04/2024 and conducted by Evaluator Arian Golbakhsh
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20241204170241
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: 180DATE:
07/16/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Associate Executive Director Aileen Spence TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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9
Staff did not prevent a resident from suffering multiple falls while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to deliver findings regarding the above-mentioned allegation. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit with Associate Executive Director Aileen Spence. Note, LPA did step out for lunch from 1-2pm.

On 12/04/2024, it was alleged that a resident (identified as R1) experienced multiple falls (11 dated listed on the complaint) between 2023 through 2024, despite being a known fall risk to the facility. The Department’s investigation consisted of unannounced facility visits, records review, and interviews with staff, residents, and outside sources.

[Continued on LIC 9099C]
Substantiated
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)
Page: 1 of 5
Control Number 08-AS-20241204170241
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]

Per review of R1's records, R1 was an identified fall risk and required the use of an assistive mobility device. According to R1's Needs & Services Plan, staff were to verbally remind R1 to utilize their assistive device or to bring it to R1 if observed not to be in use. Per file review, R1 has a documented history of seating themselves on the floor, which was also a behavior of R1's corroborated by staff during interviews. However, records review revealed that over the course of 20 consecutive months, R1 experienced 28 falls with 8 resulting in hospitalization. While 9 out of 28 were instances of R1 being found self-seated on the floor with no apparent injuries, the remaining 19 were not, and review of incident reports note that R1's assitive device was not present for a majority of R1's falls. All staff interviewed recalled R1, with some noting the R1 needed reminders to use their assistive device, but revealed conflicting beliefs of if R1 was indeed a fall risk --despite R1 being labeled one in their records. Two (2) staff interviews noted that R1 tended to be non-compliant with utilizing their assitive device. Residents and outside sources interviewed revealed no concerns regarding falls or ambulation in regards to resident needs.

Based on LPA's review of records, interviews with staff and outside sources, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. A deficiency is being cited per California Code of Regulations, Title 22, Division 6 on the attached 9099D. 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)
Page: 3 of 5
Control Number 08-AS-20241204170241
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2025
Section Cited
CCR
87464(f)(1)
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87464(f): Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidenced by:
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Licensee will submit proof of review/retraining with staff on following resident service/care plans and submit to LPA by POC due date.
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Based on file review and interviews, the licensee did not ensure R1's assistive device was present and in use as required in R1's Needs and Services Plan, resulting in a potential health and safety risk to 1 out of 180 persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
12/04/2024 and conducted by Evaluator Arian Golbakhsh
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20241204170241

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: 180DATE:
07/16/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Associate Executive Director Aileen Spence TIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff did not prevent a resident from wandering out of the facility.
Facility did not ensure that there is adequate staffing to meet the needs of the residents in care.
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. Note, LPA did step out for lunch from 1-2pm.

On 12/04/2024, it was alleged that a resident (identified as R1) had wandered out of the facility and was found in the facility parking lot. The complaint notes that R1 is a resident of the Memory Care unit of the facility and was found by visiting family members of a different resident. The Department’s investigation consisted of unannounced facility visits, records review, and interviews with staff, residents, and outside sources.

[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)
Page: 4 of 5
Control Number 08-AS-20241204170241
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-A]

Interviews with staff revealed that R1 had a history of walking for extended periods of time within the unit and attempting to enter other resident units. Some staff interviewed recalled R1 messing with door handles of the unit exit and setting off alarms occasionally, but that R1 would never attempt to exit. All staff interviewed did not recall R1 ever eloping out of the facility. However one did recall an instance where R1 may have made it out the unit doors but not the secured facility perimeter. File review of R1's records revealed that R1 has no wandering behaviors, though another notes that they do in addition to being exit seeking. Multiple files reviewed corroborated the use of a wanderguard alarm in use for R1, with staff interviews corroborating it's use. One record noted an incident where R1 was found by visitors in the facility parking lot, but no other records or interviews corroborated the incident ever occurring. Outside source interviews did not reveal any concerns regarding the security of the Memory Care unit.

In regards to the allegation regarding lack of staffing to meet resident needs, while multiple staff and outside sources indicate that they would prefer additional staffing, only one expressed that there were not enough staff to meet resident needs at all. Multiple outside source interviews revealed that during weekend or overnight shifts, it was more difficult to get a hold of staff, but stated that staff respond quickly when notified and overall felt the facility was well staffed. Resident interviews revealed that staff are generally very easy to find and responsive when called upon for assistance. Over several visits through the Memory Care unit, LPA observed a minimum of 7 staff members present at all times. File review of staff scheduled over 6 non-consecutive months revealed that there is an average of 2 med-techs scheduled during the day with 1-2 overnight and an average of 4-6 caregivers in the day with 3-5 overnight.

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)
Page: 5 of 5