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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 07/22/2025
Date Signed: 07/22/2025 06:06:39 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
01/03/2025 and conducted by Evaluator Arian Golbakhsh
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20250103101049
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: 183DATE:
07/22/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Executive Director Cathy AllenTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff did not administer medications as prescribed.
Staff did not properly assess a resident before admission.
Staff are not properly addressing wound care for the residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to conduct a complaint investigation and delivered findings regarding the above mentioned allegations. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit to Executive Director Cathy Allen. Note, LPA did step out for lunch from 12:20-1:20pm.

On 01/03/2025, the Department received a complaint where it was alleged that the facility has ongoing issues regarding medication mismanagement, such as wrong medications and omissions. It was also alleged that appropriate wound care is not being provided to residents, but did not specify further. Additionally, it was alleged that residents were being improperly assesed while at the facility. The Department’s investigation consisted of unannounced facility visits, records review, and interviews with staff, residents, and outside sources.

[Continued on LIC 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
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 2
Control Number 08-AS-20250103101049
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: 07/22/2025
NARRATIVE
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[Continued from LIC 9099]

The allegation regarding medication mismanagement did not specify any residents to whom it was occurring to or a timeline. Records review of multiple resident medication records over a period of 3-6 months around the complaint date did not reveal major discrepancies in medication administration, however, it was noted that occasionally when a new prescription is written for a resident, it takes 1-3 days for the medication to be physically present at the facility for residents. Staff interviewed corroborated that med-techs order medications or notify resident families if the resident is not enrolled with the facility's pharmacy. A few staff interviews also corroborated that medication delays come from those who's family manage orders. Resident interviews did not reveal any concerns about their medications, aside from one who indicated they experienced delays in medication refills. Review of that resident's medication record showed no delays by the facility, instead revealing that the resident refused medications. Outside sources interviewed revealed no concerns about medication management, and one expressed appreciation that the facility was strict about requiring prescription orders for all medication.

Regarding the allegation of improperly assessing a resident, records review of resident files were noted to include regularly updated resident assessments. LPA reviewed the assessment tool utilized for resident assessments and the point scale used for pricing. Staff interviews revealed that residents are assessed prior to move-in, 7 days after move in, 30 days after move in, and then every 6 months thereafter and/or if the resident experiences a change in condition in between those 6 months. Resident interviews revealed no concerns about the level(s) of care provided to them. Outside source interviews revealed that the facility was transparent and informative on the assessment procedures and breakdown of changing costs.

Regarding the allegation of wound care, the complaint only stated that appropriate wound care is not being provided. Staff interviews corroborated that the facility does not provide wound care as it is not a medical facility, and only basic first aid is provided and referrals to appropriate wound care providers. Resident and outside source interviews did not reveal any concerns about the facility's responsiveness to incidents or ability to provide necessary care. Records review indicated which residents received wound care and all were enrolled with appropriate outside agency care providers.

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 Executive Director Allen 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: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC9099 (FAS) - (06/04)
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