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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604441
Report Date: 10/10/2024
Date Signed: 10/11/2024 10:24:09 AM

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
09/12/2024 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20240912085819
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: 114DATE:
10/10/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Executive Director Adrian GuillenTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Licensee did not ensure facility grounds were free of pest
Staff spoke to resident in an inappropriate manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Adrian Guillen.

On September 12, 2024, Community Care Licensing (CCL) received a complaint alleging licensee did not ensure facility grounds were free of pest and Staff 1 (S1) spoke to Resident 1 (R1) in an inappropriate manner.

During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegation, there have been spiders, cockroaches and flees observed at the facility. Interview with Executive Director revealed that facility has a contract with a pest control company and have regular visits. Interview with staff present corroborated that a pest control company is present periodically.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
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 5
Control Number 08-AS-20240912085819
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: 10/10/2024
NARRATIVE
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Interview with residents did not reveal any information to prove the facility is not acting timely in pest control issues. Records reviewed confirmed facility has a contract in place with a pest control company.

It was also alleged that S1 made a comment to R1 that made R1 feel uncomfortable. Interview with S1 revealed that S1 did not make such statement. Interview with R1 revealed that there were no present witnessed to confirm incident. Interview with outside source could not confirm the incident occurred.

Based on LPA's interviews, record reviews and inconsistent statements there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
09/12/2024 and conducted by Evaluator Iby Strong
COMPLAINT CONTROL NUMBER: 08-AS-20240912085819

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: 114DATE:
10/10/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Executive Director Adrian GuillenTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Licensee did not keep appliances in good repair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Adrian Guillen.

On September 12, 2024, Community Care Licensing (CCL) received a complaint alleging licensee did not keep appliances in good repair.

According to allegation, mini fridge, stove top, and oven, within resident bedrooms, are not in working condition. Interview with Resident 1 (R1) revealed that R1 was informed that stove top and oven were in working condition prior to move-in. Interview also revealed that R1’s refrigerator was not maintaining food cold. Interview with Resident 2 (R2) corroborated that R2 had reported their refrigerator had been malfunctioning, but no action had been taken by facility for over six months. Interview with Maintenance Director and Executive Director revealed that facility has one full time maintenance employee and one part time maintenance employee to provide services for 115 residents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
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 5
Control Number 08-AS-20240912085819
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: 10/10/2024
NARRATIVE
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 Continued from LIC9099-A

Interview with staff also revealed that there are twelve current resident units that have appliances that are not working but such rooms are issued with “as-is” terms.

Based on interviews, a preponderance of evidence exists to support the allegations. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20240912085819
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: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2024
Section Cited
CCR
87303(a)
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Maintenance and Operation (a) the facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee agrees to provide proof of contract agreement to furnish working kitchenettes by POC date.
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This requirement was not me in evidence in:

Based on observations and interviews the licensee did not maintain appliances in good repair in 12 out of 115 persons in care posed a potential Safety and Personal Rights risk to persons 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.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5