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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604083
Report Date: 07/27/2020
Date Signed: 07/30/2020 11:07:23 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MONTERA, THEFACILITY NUMBER:
374604083
ADMINISTRATOR:JUDITH PIERFAXFACILITY TYPE:
740
ADDRESS:5740 LAKE MURRAY BLVDTELEPHONE:
(619) 832-2599
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:225CENSUS: DATE:
07/27/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Executive Director Judith PierfaxTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Debbie Correia contacted Executive Director Judith Pierfax via phone to conduct a case management visit due to COVID-19. LPA Correia identified herself to Executive Director Judith Pierfax and explained the purpose of the visit.

On July 24, 2020 the licensing agency received a death report reporting a Resident (R1) (See LIC 811 Confidential Names) passed away due Cardiopulmonary Arrest with a existing condition of a hip fracture caused by a recent fall. R1 had a diagnoses of Dementia and Cerebral Atherosclerosis, and was on Hospice at the time of death. R1's husband, who has full cognitive ability, resided at the facility with her. LPA Correia has requested R1's records for further analysis regarding R1's death.

At the time of the visit no deficiencies were observed. An exit interview was conducted with Executive Director Judith Pierfax and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) was provided to Executive Director Judith Pierfax via email. An electronic email read receipt confirms the documents were received.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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