374604083-11-19-2025-08-AS-SJAB-DP72AW-20251208161414

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 11/19/2025
Date Signed: 11/19/2025 04:55:36 PM

Unsubstantiated

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
09/23/2025 and conducted by Evaluator Amy Rodgers

COMPLAINT CONTROL NUMBER: 08-AS-20250923115541

FACILITY NAME:	MONTERA, THE		FACILITY NUMBER:	374604083
ADMINISTRATOR:	ALLEN, CATHY		FACILITY TYPE:	740
ADDRESS:	5740 LAKE MURRAY BLVD		TELEPHONE:	(619) 832-2599
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	225	CENSUS: 179	DATE:	11/19/2025
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Associate Executive Director Aileen Spenc		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Facility staff are not following resident's admission agreement
Facility staff did not respond to request for assistance in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rodgers conducted an unannounced visit to further investigate and deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to receptionist Jaqueline Aceves. Associate Executive Director Aileen Spence later joined the visit.

On September 23, 2025, it was alleged that Facility staff are not following resident's admission agreement and facility staff did not respond to request for assistance in a timely manner. The Department’s investigation included multiple observations in the memory care building—specifically in the dining and common areas, as well as individual residents’ rooms—interviews with staff and outside sources, and a review of facility procedures and staff schedules.

(Continued on LIC9099)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250923115541

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: 11/19/2025

NARRATIVE

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(Continued form LIC9099)
Regarding the allegation, the Staff are not following the resident’s admission agreement. More specifically, on two recent occasions, the resident was reportedly not checked as required, missed a scheduled medication, and did not receive assistance with food preparation due to staffing issues and shift changes. Staff interviews confirmed that Resident #1 has an individualized care plan in place and that staff are expected to follow it. Records reviewed did not indicate any medication errors, and staff schedules were provided for Department review. LPA observations during multiple unannounced visits confirmed that residents were supervised during activities and meals. Interviews with various outside sources revealed no concerns regarding staff adherence to residents’ admission agreements. This same allegation was previously investigated in March and April 2025 and found to be unsubstantiated. The Department re-evaluated the concerns during the current investigation.

Regarding the allegation, Staff did not respond to the resident’s need for help in a timely manner. More specifically, it was reported that staff delayed in assisting a resident. Additionally, during a recent evening visit, the reporting party stated they waited over an hour while seeking help before the resident was assisted and put to bed. Staff interviews revealed that radios and cellphones are used to communicate and respond to resident needs. In the memory care unit, staff also heavily rely on consistent observation to monitor residents. Staff reported they were attending to other residents at the time and denied any delays. Former Executive Director Allen stated that response times are prioritized and monitored according to protocol. Interviews with outside sources, including evening visitors, revealed no concerns about staff responsiveness. A review of records showed no documentation of delays or complaints on the date in question. A records review of staffing, specifically the memory care unit, revealed the licensee operate the facility in accordance with the terms specified in the plan of operation. LPA observations during multiple unannounced visits confirmed that staff responded promptly to residents’ needs.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Associate Executive Director Aileen Spence, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025

LIC9099 (FAS) - (06/04)

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