374604083-8-26-2021-08-AS-IESA-C6F3YD-20210831183948

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 08/25/2021
Date Signed: 08/26/2021 08:34:14 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
07/26/2021 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20210726141036

FACILITY NAME:	MONTERA, THE		FACILITY NUMBER:	374604083
ADMINISTRATOR:	MORGAN CADMUS		FACILITY TYPE:	740
ADDRESS:	5740 LAKE MURRAY BLVD		TELEPHONE:	(619) 832-2599
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	225	CENSUS: 151	DATE:	08/25/2021
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Executive Director Morgan Cadmus and Associate Executive Director Sarah John		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Licensee is not following COVID-19 health guidance.

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 welcomed by and identified himself to receptionist Peter Roberts. LPA then met with and discussed the purpose of the visit with Executive Director Morgan Cadmus and Associate Executive Director Sara John.

The Department’s investigation consisted of an unannounced tour the facility, observation of residents in care, and interviews of employees from different departments. Also reviewed was the facility’s COVID-19 Mitigation Plan Report, vaccination and testing records, and correspondence to residents and responsible parties. The complaint, which was filed on 07-26-2021, alleged that during July 2021, the licensee did not follow COVID-19 health guidance because: a) residents were not required to wearing face coverings in the Assisted Living Dining Room, and b) employees and residents were not routinely surveillance-tested for COVID-19. [CONTINUED ON LIC9099-C, 1 of 3]

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (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 4

Control Number 08-AS-20210726141036

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] On May 14, 2021, the California Department of Social Services (CDSS) published Provider Information Notice (PIN) 21-17.2-ASC, which stated, “If all residents participating in communal dining or a group activity are fully vaccinated, then residents can choose to not wear a face covering. If residents who are not fully vaccinated are present…[or] If vaccination status cannot be determined, the safest practice is for all participants to wear a well-fitting face covering (except while eating or drinking).” (This was the operative guidance on resident mask-wearing during the timeframe of the allegation.) On July 28, 2021, the California Department of Public Health (CDPH) published Guidance For The Use of Face Coverings, which stated, “Masks are required for all individuals, in the following indoor settings, regardless of vaccination status (and surgical masks are recommended):...Long Term Care Settings & Adult and Senior Care Facilities." (This was the operative guidance on mask-wearing during the timeframe of the Department’s subsequent investigation.)

On 08-04-2021, LPA walked through hallways and common areas in each of the residential buildings comprising the facility’s campus. Every resident, employee, and visitor encountered wore a face covering. Extra surgical masks were available for distribution at the front desk, along with a “Visiting Guide” handout that reiterated, “Masks are required to be worn in all common areas, hallways and corridors.” Residents seated in the Assisted Living dining room were actively eating, and each had a surgical mask either pulled down to the chin or somewhere on their person. 10 of 10 staff interviews affirmed: a) all employees are required to wear face coverings when working regardless of vaccination status, b) all residents are required to wear face coverings whenever they leave their bedroom regardless of vaccination status, except while eating, and c) these practices have long been in place, and staff remind residents as needed. The administrator produced copies of letters sent to resident responsible parties dated 05-18-2021 and 08-03-2021 respectively; they reiterated that residents must continue wearing face coverings, regardless of vaccination status, except while eating. The evidence proves the licensee’s sustained compliance with mask-wearing, both during the timeframe of the allegation, and during the timeframe of the subsequent investigation. [CONTINUED ON LIC 9099-C, 2 of 3]

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (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 4

Control Number 08-AS-20210726141036

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-C, 1 of 3]

On June 7th, 2021, CDSS published PIN 21-28-ASC, which stated, “In facilities where at least 70 percent of residents and facility staff are fully vaccinated, licensees may discontinue routine diagnostic screening testing of asymptomatic facility staff who are fully vaccinated. Licensees should test 25 percent of all asymptomatic facility staff who are not fully vaccinated at least every seven (7) days depending on the type of test used...As soon as possible after one (or more) COVID-19 positive individuals (resident or facility staff) is identified in a facility, perform serial retesting at least weekly…of all residents...and facility staff, regardless of vaccination status.” (This was the operative guidance on COVID-19 testing of staff and residents during the timeframe of the allegation.)

As revealed in staff interviews and corroborated by CDSS’ COVID-19 case database, the facility had no COVID-positive results among its residents or staff during July 2021 or the preceding four months. The facility was thus not required to COVID-test asymptomatic residents. Also revealed in staff interviews and corroborated by the facility’s vaccination logs (which were themselves cross-referenced against CDSS’ prior-collected vaccination data), as of 08-04-21: 141 of 143 residents (98.6%) were fully vaccinated and 73 of the 77 staff (94.8%) were fully vaccinated. The facility was thus not required to COVID-test their asymptomatic, fully vaccinated employees. Of the four unvaccinated staff, Staff #1 (S1) and Staff #2 (S2) had medical exemptions while Staff #3 (S3) and Staff #4 (S4) had religious exemptions. Testing records show in the 30 days preceding the complaint, S1 was on an extended leave of absence, S2 was negative on a polymerase chain reaction (PCR) test and two rapid antigen tests, S3 was negative on two PCR tests, and S4 was negative on two rapid antigen tests. Licensee therefore met CDSS’ 25% weekly unvaccinated staff testing recommendation.

[CONTINUED ON LIC 9099-C, 3 of 3]

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (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: 3 of 4

Control Number 08-AS-20210726141036

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-C, 2 of 3]

On July 27th, 2021, CDSS published PIN 21-32-ASC, which announced upgrades to the diagnostic testing regimen to take effect by 08-09-2021. Under the new PIN, 100% of asymptomatic staff who are not fully vaccinated must be tested weekly, as opposed to 25%. On 07-29-2021 (10 days before the implementation deadline), the facility increased its testing pace: S1 was negative on a blood test, S2 was on a leave of absence, S3 was negative on the first of two negative rapid antigen tests, and S4 was negative on a PCR test. Then on 08-03-2021, Staff #5 (S5), who was fully vaccinated, developed symptoms and tested positive on a rapid antigen test. By the time of LPA’s unannounced visit on 08-04-2021, 10 of 10 staff interviewed stated the facility had already announced a mass serial test of all staff and all residents, regardless of vaccination status, to begin 08-05-2021. This mass serial test was also described in an 08-03-2021 letter from the administrator to all employees and residents/responsible parties. The facility later conducted a second serial mass test on 08-12-2021. Both of these mass serial tests results in all negative results. The evidence proves the licensee’s sustained compliance with COVID-testing, both during the timeframe of the allegation, and during the timeframe of the subsequent investigation.

Based on observations, interviews, and record review, the above allegation was determined to be unfounded, meaning the allegation was false, could not have happened, and/or is without a reasonable basis. We have therefore dismissed the complaint. 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 Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (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)

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