374604441-12-26-2023-08-AS-JLOT-CYYUB2-20231229142538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604441
Report Date: 12/26/2023
Date Signed: 12/26/2023 01:42:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
03/09/2023 and conducted by Evaluator Nacole Patterson

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20230309131053

FACILITY NAME:	MONTE VISTA VILLAGE SENIOR LIVING		FACILITY NUMBER:	374604441
ADMINISTRATOR:	MARKOVICH, PAUL		FACILITY TYPE:	740
ADDRESS:	2211 MASSACHUSETTS AVENUE		TELEPHONE:	(619) 465-1331
CITY:	LEMON GROVE	STATE: CA	ZIP CODE:	91945
CAPACITY:	219	CENSUS: 120	DATE:	12/26/2023
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Monica Maldonado, Resident Services Director		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Unqualified staff dispensing medication.
Staff pre-poured medications.
Staff did not assist with medication as prescribed.
Lack of supervision resulted in resident AWOL.
Staff did not meet resident(s) incontinence needs.
Staff did not meet resident(s) basic needs.
Staff did not treat resident(s) with dignity.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Monica Maldonado, Resident Services Director.

On 3/9/23 it was alleged that unqualified staff dispensed medication, staff pre-poured medications, staff did not assist with medication as prescribed, lack of supervision resulted in resident AWOL, staff did not meet residents' incontinence needs, staff did not meet residents' basic needs, and staff did not treat residents with dignity. The Department’s investigation consisted of unannounced facility visits, review of relevant records, interviews with facility staff, residents, and outside sources.

Regarding the allegation, "Unqualified staff dispensing medication", it was alleged that the Medication Technicians "Med Techs" did not receive the required amount of training hours before assisting residents
with medication. (Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

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-20230309131053

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MONTE VISTA VILLAGE SENIOR LIVING	FACILITY NUMBER: 374604441
	VISIT DATE: 12/26/2023

NARRATIVE

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(Continued from LIC9099)

Staff interview revealed that Med Techs receive the required number of training hours through a combination of pharmacy training, seminars, and hands-on shadowing. No staff interviewed were aware of untrained staff administering medications. Review of facility records did not corroborate the allegation, revealing pharmacy certifications for Med Tech staff. Resident interviews did not corroborate the allegation; residents did not express concern regarding medication administration, stating their medications were given on time and correctly. Outside sources did not respond for interview.

Regarding the allegation, "Staff pre-poured medications", it was alleged that Med Techs were instructed to prepare medications in advance, to be administered at a later time and by other staff members. Staff interview revealed that staff prepare medication immediately before administering them. Residents interviewed did not have knowledge regarding the preparation of medications. No records were found to corroborate that the preparation for medication exceeded the guidelines in order to be considered a "pre-pour". Outside sources did not respond for interview.

Regarding the allegation, "Staff did not assist with medication as prescribed", it was alleged that staff refused to administer a pro re nata (PRN) medication upon request, and forged medication counts after misplacing medication. Staff interviews did not corroborate the allegation, as no staff advised witnessing or being informed of a Med Tech not providing a PRN when requested. Staff interviews with records corroboration further revealed that the medication in question was not misplaced, but had been turned in to management and disposed of, per requirement. The resident in question (R2) denied the allegation, stating that staff were helpful and provided their medications on time and upon request when needed. Outside sources did not respond for interview.

Regarding the allegation, "Lack of supervision resulted in resident AWOL", it was alleged that a resident was found multiple times wandering away from the facility. Staff interview revealed that the facility does not have a memory care unit and staff are not allowed to prevent residents from entering or leaving the facility of their own will. Staff interview further revealed that the resident in question (R3) experienced an acute change in condition and the Licensee updated the resident's care plan; Licensee also maintained contact with their physician and responsible party. R3 was transferred to a different facility that provided a higher level of care. R3 was unable to be interviewed.

(Continued on LIC9099-C)

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230309131053

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MONTE VISTA VILLAGE SENIOR LIVING	FACILITY NUMBER: 374604441
	VISIT DATE: 12/26/2023

NARRATIVE

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(Continued from LIC9099-C)

Records review confirmed that the facility does not have a memory care unit and is not approved for delayed egress doors to keep residents from exiting the building. Records review further revealed that the resident was able to leave the facility unassisted, and the Licensee updated the resident's care plan when the change in condition was observed. Outside sources did not respond for interview.

Regarding the allegation, "Staff did not meet resident(s) incontinence needs", it was alleged that residents were not assisted with incontinence care per their needs and were declined help upon request. Staff interviews did not corroborate the allegation; staff members interviewed denied observing or being informed of a staff member refusing to change a resident when needed. Residents interviewed did not receive incontinence services, therefore were not able to provide information regarding incontinence care. The resident in question (R4) was not able to be interviewed due to no longer living at the facility. Records review revealed that R4 began experiencing confusion that resulted in them requesting to be changed multiple times per hour and when no incontinence had occurred. Records review further revealed that R4 was assisted when requests for incontinence help were made. Outside sources did not respond for interview.

Regarding the allegation, "Staff did not meet resident(s) basic needs", it was alleged that staff were instructed not to assist Independent Living residents, and the main building was not open for service according to the listed hours, resulting in basic needs not being met. Staff interview revealed that caregivers and Med Techs were mostly concentrated in buildings 5 and 17, the Assisted Living buildings, but also helped the Independent Living residents when needed. Resident interviews did not corroborate the allegation, informing that Independent Living residents were able to call for, and receive, assistance when needed. No records reviewed gave supporting evidence of Independent Living residents not receiving help from staff. Outside sources did not respond for interview.

Regarding the allegation, "Staff did not treat resident(s) with dignity", it was alleged that staff member(s) yelled at a resident(s), pushed a resident, and threw a towel at a resident.

(Continued on LIC9099-C)

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20230309131053

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MONTE VISTA VILLAGE SENIOR LIVING	FACILITY NUMBER: 374604441
	VISIT DATE: 12/26/2023

NARRATIVE

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(Continued from LIC9099-C)

Staff interviews were mixed, informing that one of the staff members of concern exhibited impatience with residents when they were overwhelmed, but no staff witnessed or corroborated the specific situations named. Resident interviews did not corroborate the allegation, as residents stated staff treat them well. Two residents named in the allegation were unable to be interviewed. Records review revealed that the facility reported the accusation of staff pushing a resident, but the internal investigation was inconclusive. Outside sources did not respond for interview.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Monica Maldonado, Resident Services Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC9099 (FAS) - (06/04)

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