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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 09/18/2025
Date Signed: 09/18/2025 01:02:02 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
09/03/2025 and conducted by Evaluator Ramin Hashemi
COMPLAINT CONTROL NUMBER: 08-AS-20250903081207
FACILITY NAME:MONTERA, THEFACILITY NUMBER:
374604083
ADMINISTRATOR:ALLEN, CATHYFACILITY TYPE:
740
ADDRESS:5740 LAKE MURRAY BLVDTELEPHONE:
(619) 832-2599
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:225CENSUS: 183DATE:
09/18/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Cathy Allen, Executive Director TIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Lack of supervision resulted in resident elopement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegation(s). LPA introduced themselves and disclosed the purpose of the visit to Cathy Allen, Executive Director.

On 9/03/2025 it was alleged that lack of supervision resulted in resident elopement. The Department’s investigation consisted of an unannounced facility visit, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations.

Staff interviews revealed that Resident 1 (R1) eloped from the facility around 4:20pm and was returned to the facility by La Mesa PD at 5:15pm. Staff were not aware of how R1 was able to leave memory care unassisted nor were they aware of the R1's absence from the facility until La Mesa PD returned R1. Staff 2 (S2) and Staff 3 (S3) stated they believed at the time of R1's elopement, R1 was with Resident 2 (R2) who often shares meals with R1.
(Continued on page 2, LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
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 3
Control Number 08-AS-20250903081207
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: 09/18/2025
NARRATIVE
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(Continued from page 1, LIC9099)

Resident interviews revealed that R1 did not know how they were able to leave and could not identify the person(s) who helped them elope from the facility. R2 stated they were not with R1 the day of the incident. This corroborates that staff were not aware of R1's location or whom they were with.

Outside Source Interviews revealed that when S1 was asked how R1 was able to leave memory care, that it was possible "R1 left while another resident was moving into memory care."

Records review revealed that R1 requires a "secured Memory care due to the diagnosis of dementia and serious cognitive impairment with a history of wandering and exit seeking behavior." Per the general absentee notification plan for all residents, staff are to notify police within 30 minutes of elopement if the resident is not located. Staff were unable to follow the absentee notification plan due to lack of knowledge of resident's absence. Records review corroborated the need of supervision for R1.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and are therefore substantiated.  Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D).  A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Cathy Allen, Executive Director, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20250903081207
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: 09/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
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In reposnse to the event, admin completed elopement drills and parameter alarms/security training. Administrator agreed to obtain internal source training for all staff on personal rights and dementia training. Admin will submit proof of training by 10/15/25.
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Based on observation, interviews, and record
review, the licensse did not ensure that care, supervision, and services that meet their individual needs. This posed a Health, Safety, and Personal rights risk to one (1) of one-hundred and eighty-four (184) 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: Simon Jacob
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3