Staff interviews revealed when anyone has grievances, that are brought to the management's attention, there is an active internal investigation and a response to the grievance. The facility has records of the grievances that were investigated by the Department and if needed a plan of correction.

Outside sources were interviewed and there were no complaints regarding the facility addressing any grievances promptly. Most of the Outside sources that were interviewed stated there have not been any grievances regarding the facility, the staff and or the care at the facility.

This agency has investigated the complaint alleging that staff are not meeting residents' needs due to inadequate staffing. 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.

On February 12, 2025, the department received a complaint alleging retaliation against resident for exercising their rights at the facility.

Records reviewed revealed the Montera Executive Director, Associate Executive Director, Risk Manager and upper management have not retaliated against resident for exercising their rights at the facility.

Staff interviews revealed they are trained to not retaliate against any resident for exercising their rights at the facility. The staff are in services at least one time per year regarding resident rights.

Outside sources were interviewed and there were no complaints regarding the facility addressing any grievances promptly. Most of the Outside sources that were interviewed stated there have not been any grievances regarding the facility, the staff and or the care at the facility.

Residents were interviewed and they did not express any staff retaliation against them for exercising their rights at the facility. The resident's all expressed that the staff are very respectful and they feel they are treated with dignity.

This agency has investigated the complaint alleging that staff are not meeting residents' needs due to inadequate staffing. 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.

Records reviewed revealed the Montera Executive Director, Associate Executive Director, Risk Manager and upper management have not retaliated against a resident advocate.

Staff interviews revealed they are trained to not retaliate against any resident advocate. The staff are in services at least one time per year regarding resident rights.

Outside sources were interviewed and there were no complaints regarding retaliation of a resident advocate. Most of the Outside sources that were interviewed stated there have not been issues regarding retaliation of a resident advocate or retaliation whatsoever.

Residents were interviewed and they did not express any retaliation of a resident advocate. The resident's all expressed that the staff are very respectful to them and their advocates.

This agency has investigated the complaint alleging that staff are not meeting residents' needs due to inadequate staffing. 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.

On February 12, 2025, the department received a complaint alleging facility management not responsive to the resident's advocate.

Records reviewed revealed the Montera Executive Director, Associate Executive Director, Risk Manager and upper management have responded to the resident's advocate.

Outside sources were interviewed and there were no complaints regarding facility management not responsive to the resident's advocate. Most of the Outside sources that were interviewed stated there have not been issues regarding the facility management not responsive to the resident's advocate.

Residents were interviewed and they did not express any concerns regarding facility management not responsive to the resident's advocate.

In regard to the allegation of Licensee did not allow resident's right to participate in care plan meeting. There were documented care plan meetings on the following dates 9/19/24, 9/24/24,11/22/24 for Resident 1 (R1).

Interviews with Staff revealed that multiple offers of a care plan meeting was requested with R1 and the offered times and dates were often changed to accommodate R1.

Interviews with Outside sources revealed they had no concerns regarding care plan meetings and the facility was always accommodating to requested times and dates so that the resident can participate in the meetings.

Residents were interviewed and there were no concerns regarding participating in care plan meetings.

This agency has investigated the complaint of Licensee did not allow resident's right to participate in care plan meeting. 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.

In regard 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.

This agency has investigated the complaint alleging that staff are not meeting residents' needs due to inadequate staffing. 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.

It was alleged that staff are not meeting residents' needs due to inadequate staffing. Staff 1 (S1) was interviewed and provided a statement that when a family member requested an adult brief change, S1 requested the assistance of another staff member and provided care to the resident. Staff 2 (S2) concurred with S1 and assisted with changing the resident as soon as the family requested assistance.

Outside Source 1 (OS1) was interviewed and there were no complaints regarding inadequate staffing.

Outside Source 2 (OS2) was interviewed regarding the facility staffing and there were no concerns or complaints regarding having adequate staffing to care for the residents. Outside Source 3 (OS3) was interviewed and there were no concerns regarding staff; OS3 stated there were sufficient staffing. Outside Source 4 (OS4) was interviewed and there were no concerns regarding staffing.

Records review did not show evidence that staffing numbers were inadequate to meet the basic needs of residents and/or to assist with their requests. On 3 unannounced facility visits, LPA directly observed caregivers assisting residents with Activities of Daily Living (ADLs), medication, activities, and using walkie-talkies to communicate with other staff.

This agency has investigated the complaint alleging that staff are not meeting residents' needs due to inadequate staffing. 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.

Interviews with hospice agencies that care for residents at the facility reveal they are not aware of any hospice violations.

Review of records show that there are extensive notes on the care of the residents on hospice care with the following medical doctor, the staff at the facility and internal communication with the hospice staff that visit and care for the resident on hospice care.

Interviews with Outside sources reveal no concerns with the hospice care at the facility for the residents.

Interviews with staff reveal extensive communication with the staff on visit days, how the resident is doing and any changes with the resident.

This agency has investigated the complaint alleging the resident council rights are not posted in a prominent place at the facility. 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.

It was alleged that the resident council rights are not posted in a prominent place at the facility. LPA Domingo observed during several unannounced visits that there is a resident council rights posted in a prominent place at the facility. Upon entering the facility lobby. To the right there is a stairwell that has a large framed poster with the resident council rights. The poster is easy to read and in a prominent location at the facility.

This agency has investigated the complaint alleging the resident council rights are not posted in a prominent place at the facility. 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.

The Department also reviewed caregiver work schedules and date and time-stamped electronic data from the facility’s signals system.

CCLD studied the signal data for five (5) randomly selected, twenty-four-hour days, chosen from the complaint allegation period. During the surveyed days, there were a total of 186 resident pendant calls, of which were answered by staff in ten (10) minutes or less, and a few were answered by staff in fifteen (25) minutes or less. Work schedules showed that on the surveyed days, Licensee consistently utilized third-party staffing agencies, when needed, to plug/fill staffing vacancies which were not already filled internally by facility caregivers.

The interview with the Executive Director explained that a pendant is given to the resident, and interviews with staff, resident family members, and an outside source do not corroborate the allegation.

Staff members' interviews reveal that they use a radio system to communicate and cooperate to respond within a few minutes of each resident's request for help using their call button.

Documentation further showed that facility managers met several times per week to review and discuss signal report data from a quality assurance standpoint.

LPA observations on several occasions confirm that call button requests are responded to promptly.

Interviews of Medication Technicians and Caregivers showed a pattern of teamwork, communication, and clarity of expectation, as it related to responding to resident signal alerts.

This agency has investigated the complaint alleging Residents have a lengthy call light response from staff. 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 with Associated Executive Director Aileen Spence to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Interview with the Executive Director (ED) confirmed that on December 30, 2024, the 30-day eviction letter was given to R1 and mailed to their responsible party. The eviction letter provided to R1, did not contain specific facts; such as date, place, and circumstances concerning the reason for eviction. The ED stated that on December 20, 2024, the Director of Health Services conducted a reappraisal of R1’s condition and determined that R1 had a change of condition and new care needs. The ED stated that R1 was only allowing a few specific caregivers to assist with R1’s activities of daily living as required by the service plan. On December 20, 2024, R1 requested to have two (2) caregivers to no longer provide care for them. As a result, the ED stated there are insufficient number of remaining caregivers at the facility to meet R1’s needs.

The Department requested the resident assessment conducted December 20, 2024, which led to the eviction, however, the facility had no record of the assessment. In addition, the facility has no records of a care conference addressing R1's change of condition for this assessment. There were no records verifying the Medical Physician was notified of R1's of change of condition.

Interview with Outside source (OS1) confirmed that the facility did not conduct a care plan conference addressing R1's change in condition or resident assessment on December 20, 2024, which led to the eviction.

The Department investigated the above allegation, and the preponderance of the evidence standard was met. Therefore, the above allegation is substantiated. A deficiency was cited in accordance with the California Code of Regulations, Title 22 and is documented on the attached 9099-D. An exit interview was conducted with Associate Executive Director Aileen Spence and a plan of correction was jointly developed. A copy of these reports along with Licensee/Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit.