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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604441
Report Date: 07/15/2026
Date Signed: 07/15/2026 03:03:53 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
11/14/2023 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20231114155113
FACILITY NAME:MONTE VISTA VILLAGE SENIOR LIVINGFACILITY NUMBER:
374604441
ADMINISTRATOR:ADRIAN GUILLENFACILITY TYPE:
740
ADDRESS:2211 MASSACHUSETTS AVENUETELEPHONE:
(619) 465-1331
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:219CENSUS: DATE:
07/15/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director Adrian GuillenTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Licensee did not safely maintain facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to address the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Executive Director Adrian Guillen

The Department’s investigation included an unannounced visit, interviews with residents and facility staff, observations, and review of relevant facility documentation.

It was alleged that the facility Licensee did not safely maintain facility. More specifically, the Reporting Party (RP) alleged: The facility pool contains algae ; Cracked sidewalks near the gazebo causing residents to fall; Ceiling areas opened due to construction allegedly expose mold and dust; residents reportedly inhaling the particles; Palm trees are not adequately maintained, and large palm fronds fall into walkways; one resident was reportedly struck in the head.
(Continued on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
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-20231114155113
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: MONTE VISTA VILLAGE SENIOR LIVING
FACILITY NUMBER: 374604441
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2026
Section Cited
CCR
87307(b)
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87307(b) – Buildings and Grounds: Safety Hazards“The facility shall be free of hazards, including but not limited to… outside walkways, porches, and yard areas...not maintained to prevent resident harm.This requirement has not been met as evidenced by:
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The Executive Director will ensure removal of all dead and hanging palm fronds. A copy of the service order will be submitted to CCLD by the due date.
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Based on LPA observations, interviews, and photographic evidence, the facility grounds were not maintained in a manner that ensured resident safety. Failure to properly maintain the palm trees and remove hazardous debris poses a potential health and safety risk to residents 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.
SUPERVISOR'S NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 08-AS-20231114155113
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: MONTE VISTA VILLAGE SENIOR LIVING
FACILITY NUMBER: 374604441
VISIT DATE: 07/15/2026
NARRATIVE
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(Continued from LIc9099)

Regarding the Dining Room Mold / Ceiling Areas: No evidence could be found regarding details of construction. Interviews with the Executive Director confirmed construction had occurred on the first and second floors to replace portions of the dropped/false ceiling in lounge areas. The Executive Director reported no mold was observed or reported during the construction work. A review of incident reports and interviews with residents confirmed no adverse effects from ceiling work were reported to the facility or to CCLD. Interviews with residents reveal remembering the construction but not the details or recalling anyone being adversely effected by the construction.
Regarding the Pool Mold/Algae: Resident and staff interviews revealed the pool occasionally appears discolored; however, residents also stated the pool is generally well maintained and that most residents do not regularly use it. The Executive Director reported the pool is maintained by an outside vendor and any issues are addressed promptly. No evidence of hazardous neglect was found.
Regarding the Sidewalk Hazards: LPA observations and review of other complaint investigations confirm that sidewalk concerns were previously addressed under a separate complaint. No new findings were discovered during this investigation.
Regarding the Palm Tree Maintenance: LPA observations, interviews, and photographic evidence confirmed that numerous palm trees on the property had dead, hanging fronds and fallen debris in walkways. Resident interviews revealed the fronds were observed obstructing common walking paths, but no evidence could be confirmed that any residents were harmed. Records showed only one trimming during the complaint period on 2/21/24. The facility grounds were not maintained in a manner that ensured resident safety.

Based on LPA observations, photo evidence, resident interviews, and records review, the Licensee did not ensure the grounds were free of hazards. Large numbers of palm trees contained dead and hanging fronds. Records show the last trimming occurred on 02/21/2024, and no additional trimming has been documented. This posed a potential safety hazard to residents who use walkways. Therefore, the allegation is deemed substantiated,  and one (1) deficiency was cited for it per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Executive Director Adrian Guillen, 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: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
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