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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604441
Report Date: 10/10/2024
Date Signed: 10/11/2024 10:22:00 AM

Document Has Been Signed on 10/11/2024 10:22 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
374604441
ADMINISTRATOR/
DIRECTOR:		ADRIAN GUILLENFACILITY TYPE:
740
ADDRESS:2211 MASSACHUSETTS AVENUETELEPHONE:
(619) 465-1331
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY: 219CENSUS: 114DATE:
10/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Executive Director Adrian GuillenTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management Visit to cite a deficiency which was identified during a separate complaint investigation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Adrian Guillen.

During a complaint investigation LPA Strong reviewed Resident 1's (R1) Admissions Agreement and found that that the admissions agreement contains a written agreement to waive facility responsibility of the in regards to safety and healthful equipment and accommodations. According to the agreement "Unless the Resident notifies the Community in writing of any alleged defect in the Apartment prior to the commencement of the Term, the Resident shall be deemed to have accepted the Apartment in an 'as-is' condition.....The Community reserved the right to inspect all electrical equipment and appliances for safety and to forbid their use in the Community should they be determined to be hazardous".

Based on records reviewed a deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). An exit interview was conducted with Executive Director Adrian Guillen. A copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to her during today’s visit.

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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/11/2024 10:22 AM - It Cannot Be Edited


Created By: Iby Strong On 10/09/2024 at 04:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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)
Deficiency Dismissed
Type B
11/07/2024
Section Cited
CCR
87507(h)(2)

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Admission Agreements- The admission aggreement shall not contain the (2) Written agreements to waive facility responsibility or liability for the health, safety or the personal property of residents, or the provision of safe and healthful facilities, equipment and accommodations.
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Licensee agrees to create an addendum to admissions agreement and provide proof to LPA by POC.
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Based on records reviewed the licensee included language in the admissions agreement that threatens the residents healful accomodations in one of 115 residents in care which posed a 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.
SUPERVISOR'S NAME:Simon Jacob
LICENSING EVALUATOR NAME:Iby Strong
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024


LIC809 (FAS) - (06/04)
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