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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336424970
Report Date: 08/19/2022
Date Signed: 08/19/2022 11:36:04 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2022 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220811142049
FACILITY NAME:MONTAGE MANORFACILITY NUMBER:
336424970
ADMINISTRATOR:CYNDY ZAECHFACILITY TYPE:
740
ADDRESS:69-920 MATISSE RDTELEPHONE:
(760) 699-5090
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:6CENSUS: 6DATE:
08/19/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Vanessa Franco, House ManagerTIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
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5
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7
8
9
Resident not administered medication as prescribed.
INVESTIGATION FINDINGS:
1
2
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5
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9
10
11
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13
Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to investigate the above allegation. LPA conducted an inspection of the facility, and interviewed staff, and a resident.

Review of documents and interviews with staff and Licensee revealed resident 1 (R1) has been receiving medication as ordered by Physician. During an inspection of the facility on 8/19/22, LPA did not observe any over the counter medications that were associated to R1. Staff and Licensee also stated that over the counter medications were not being provided.

Continued on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
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 2
Control Number 18-AS-20220811142049
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MONTAGE MANOR
FACILITY NUMBER: 336424970
VISIT DATE: 08/19/2022
NARRATIVE
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LPA conducted interviews, and received documents in relation to this complaint which both revealed that medication is being administered as ordered by the Physician.

Thus this complaint is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was discussed with and provided along with a copy of the LIC9099-C, and LIC811.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2