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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 08/25/2021
Date Signed: 08/26/2021 08:56:10 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/12/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20210112160326
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: 151DATE:
08/25/2021
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Executive Director Morgan Cadmus and Associate Executive Director Sarah JohnTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Licensee did not provide resident's representative a copy of the admissions agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Complaint Visit to deliver a finding regarding the above allegation. LPA was greeted by and identified himself to receptionist Peter Roberts. LPA then met and discussed the purpose of the visit with Executive Director Morgan Cadmus and Associate Executive Director Sarah John.

It was alleged that the licensee did not provide Resident #1’s (R1) authorized representative with a copy of a signed and dated current admission agreement. The Department’s investigation consisted of reviewing administrative records for R1, as well as for randomly selected Resident #2 (R2) and Resident #3 (R3), who moved into the facility within a 90-day period of R1 (see LIC 811 Confidential Names List for identification of R1 and R3). It also included interviews of current and former facility staff and pertinent resident representatives. [CONTINUED ON LIC 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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-20210112160326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MONTERA, THE
FACILITY NUMBER: 374604083
VISIT DATE: 08/25/2021
NARRATIVE
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[CONTINUED FROM LIC 9099]

It was revealed that R1’s authorized representative requested from licensee a copy of their signed and dated admissions agreement at the time of its execution, but one was not provided. The representative reiterated the request over a month later. This request was verbally acknowledged, but it was not followed through upon. Additionally, the authorized representative for R2 received a copy of their respective signed and dated admissions agreement, but the authorized representative for R3 did not receive theirs. In all three instances, the representative was the signatory on the admissions agreement for their respective resident. Per California Code of Regulations, Title 22, Section 87507, a licensee must provide a copy of the signed and dated admissions agreement to each resident’s representative immediately upon signing or modification, and again upon the representative’s request.

Based on record review and interviews, a preponderance of evidence exists and the allegation is substantiated. A deficiency is cited per California Code of Regulations, Title 22; refer to the attached LIC 9099-D. Although R1, R2, and R3 each moved into the facility prior to the tenures of Executive Director Morgan Cadmus and Associate Executive Director Sarah John, a Plan of Correction was jointly developed with them. An exit interview was conducted with Cadmus and John, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210112160326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MONTERA, THE
FACILITY NUMBER: 374604083
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2021
Section Cited
CCR
87507(e)
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Admissions Agreement: "The licensee shall provide a copy of the signed and dated current admission agreement…to the…resident's representative, if any, immediately upon signing…The licensee shall provide additional copies…upon request." This requirement is not met as evidenced by:
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During the visit, LPA provided retraining on regulation 87507(e) to all local staff currently authorized to sign admission agreements, which was documented on a sign-in sheet. One copy remains at the facility,
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Based on interviews and record review, the licensee did not provide a copy of the signed and dated admissions agreement to representatives for R1 and R3, which posed a potential impact on the facility’s plan of operation.
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and one copy was given to LPA. Administrator shall deliver copies of admission agreements to representatives of R1 and R3, and send proof of their delivery to LPA by the POC due date.
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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.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3