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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604083
Report Date: 11/18/2025
Date Signed: 11/18/2025 08:20:03 PM

Unfounded


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
10/14/2025 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20251014094946
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: 179DATE:
11/18/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Operation Specialist Emily TurnerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility failed to provide responsible party with call button logs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Operation Specialist Emily Turner.

The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, and records review.

On October 13, 2025, it was alleged that the facility failed to provide the responsible party(RP) with the resident’s call button logs. More specifically, the Licensee failed to respond to multiple requests for the resident’s pendant report prior to a scheduled care planning meeting.
(Continued on LIC9099C)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
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 4
Control Number 08-AS-20251014094946
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: 11/18/2025
NARRATIVE
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(Continued from Lic9099)

The department conducted a Records Review and reviewed the email chain submitted by the RP, which was identical to the documentation submitted in prior complaints and was previously investigated in February and July 2025. No new incident or evidence was introduced.

Based on records and interviews, the allegation that the Licensee failed to provide the responsible party with call button logs is UNFOUNDED, meaning it is false, could not have happened, and/or is without a reasonable basis. The Department has therefore dismissed this allegation.

An exit interview was conducted with [Administrator/Designee Name], 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: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
10/14/2025 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20251014094946

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: 179DATE:
11/18/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Operations Director Emily TurnerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
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9
Insufficient staffing to meet residents needs
Facility retaliated against resident
INVESTIGATION FINDINGS:
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*****This is an amended documet****
Licensing Program Analyst (LPA) Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Operations Director Emily Turner.

The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, and records review.

On October 13, 2025, it was alleged that the facility had insufficient staffing to meet residents’ needs and that the facility retaliated against a resident. More specifically, the reporting party(RP) alleged that the facility continues to assign a caregiver with a history of misconduct to the resident #1 (R1) room, despite their objections. RP also alleged that R1 pendant calls go unanswered for extended periods, and that staff are retaliating against the resident for requesting caregiver reassignment. (Continued from LIC9099)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20251014094946
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: 11/18/2025
NARRATIVE
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(Continued from LIC9099)

The Department’s interviews with R1 revealed that they experienced delayed pendant responses on multiple occasions, including a specific incident on October 12, 2025, during which they stated that staff did not respond for over 90 minutes. R1 also reported a retaliatory comment from a staff member. R1 further revealed they had requested Staff #1 not to be assigned to help them and one time R1 witnessed Staff #1(S1) in the hallway outside their room.

The Department conducted a records review over a random 10-day period for the floor where Resident #1 (R1) resides as well as the R1's own call log. During this time, call logs showed average response times ranging from 10 to 13 minutes for the floor on which R1 resides. R1 activated their call light 81 times, with an individual average response time of 12.19 minutes. As part of the review, it was noted that on October 12, 2025, R1 requested assistance using the call light four times between 5:00 a.m. and 8:30 a.m., with an average response time of 14.25 minutes for those calls. The department also conducted Interviews with other residents on the same floor and they revealed very little concern with call response times, stating they occasionally will experience more delay in the morning, and they feel the delayed response may be due to the number of residents getting up at the same time and needing assistance.

The department interviewed staff and they confirmed S1 is not assigned to the resident but may occasionally may be stationed or work outside the room of R1.  Staff also revealed that routinely, two caregivers are assigned to respond to R1 requests to ensure staff safety and accountability. The department interviewed multiple care staff, and they denied they made retaliatory comments to R1. Interviews conducted with other residents on the same floor as well as residents within the community revealed no concerns with staff behavior when they need assistance nor have they witnessed retaliatory comments from staff.

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 Operations Director Emily Turner, 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: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4