374604441-2-13-2025-08-AS-LTEZ-DEB3FH-20250227171245

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604441
Report Date: 02/13/2025
Date Signed: 02/13/2025 04:51:15 PM

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
06/26/2024 and conducted by Evaluator Sabel Martinez

COMPLAINT CONTROL NUMBER: 08-AS-20240626104728

FACILITY NAME:	MONTE VISTA VILLAGE SENIOR LIVING		FACILITY NUMBER:	374604441
ADMINISTRATOR:	ADRIAN GUILLEN		FACILITY TYPE:	740
ADDRESS:	2211 MASSACHUSETTS AVENUE		TELEPHONE:	(619) 465-1331
CITY:	LEMON GROVE	STATE: CA	ZIP CODE:	91945
CAPACITY:	219	CENSUS: 113	DATE:	02/13/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Executive Director Adrian Guillen		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

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Facility wrongfully evicted a resident.
Licensee did not provide a refund.
Staff did not report an injury to a resident’s responsible party.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Adrian Guillen.

Throughout the investigation, the Department secured records and conducted interviews with external and internal sources.

It was alleged the facility wrongfully evicted a resident. It was reported to the Department the facility forced Resident # 1(R1)’s family and responsible party to move R1. The facility allegedly assessed R1, determined the level of care had increased, and notified the responsible party fees would be increased. The facility allegedly refused to discuss a care plan with R1’s family and R1’s hospice agency.

(See LIC 9099C for continuation of report.)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240626104728

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: 02/13/2025

NARRATIVE

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Interviews with staff revealed R1 would become aggressive and often would hit and bite staff. Staff consistently mentioned R1 had these behaviors since R1’s admission to assisted living.

Interviews with the facility’s Resident Service Director (RSD) and Executive Director (ED) confirmed R1 was re-assessed and a change of level of care was determined. R1's decline had progressed and aggressive behaviors had increased in frequency and severity. R1 would hit, bite and not allow staff to provide assistance, or care. The ED and RSD notified R1’s responsible party of this change and advised the monthly fees would be increased. The ED reported the responsible party disclosed the responsible party would not be able to pay the new monthly fees. The responsible party agreed to move R1 to new facility and did so within a few days, before the new monthly fees were charged. An eviction was not discussed as the resident moved out.

An interview with an outside source revealed R1’s family member had vented about having to find a new placement for R1. This source did not have any reports noting the facility had pressured R1’s responsible party to move R1.

The LPA attempted several contacts with R1’s responsible party, but these were unsuccessful. Based on the investigation, there was not enough evidence to determine the facility wrongfully evicted R1, therefore, the allegation was unsubstantiated.

It was alleged the licensee did not provide a refund. It was reported to the Department a refund was provided to R1’s responsible party, but this amount was inaccurate.

The LPA reviewed facility records, including R1’s admission agreement, face sheet, refund form and ledger. R1 was admitted to the facility on January 10th, 2022 and moved out May 18th, 2024. R1 paid four thousand five hundred dollars ($4,500) for the month of May. R1 was assessed a late fee of two hundred fifty dollars ($250), and a refund for one thousand six hundred eighty-seven dollars ($1687) was provided. This amount matched the amount provided to the LPA by the reporting party.

The LPA attempted to contact R1’s responsible party on several occasions to confirm monthly fees, late fees, and the amount of refund, but these attempts were unsuccessful. The allegation was unsubstantiated.

(See the additional LIC 9099C for continuation of report.)

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240626104728

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: 02/13/2025

NARRATIVE

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It was alleged staff did not report an injury to a resident’s responsible party. In was reported to the Department R1 sustained a bruise on R1’s forehead. That R1’s responsible party was notified of this bruise during a visit to the facility on R1’s birthday.

Interviews with staff revealed it was the facility’s protocol to notify physicians, and the residents’ responsible parties when injuries or bruises were sustained. R1 was on hospice, bedridden and bruises were common, as R1 may bump arms against bedrails. These staff members did not recall ever witnessing any bruises on R1’s forehead. Review of narrative charting notes obtained from the facility revealed Staff #1 (S1) noted a bruise on R1’s forehead on the morning of February 28th, 2024, R1’s birthday. S1 also noted a nurse was notified of the bruise. When interviewed, S1 confirmed it was the facility’s protocol to provide first aid as needed, notify physicians, and responsible parties. S1 was not able to recall the incident in question, therefore, S1 was not able to recall who was notified on that date.

An interview with R1’s hospice service provider did not reveal any information corroborating R1’s responsible party was not notified of such bruise. The LPA attempted multiple contacts with R1's responsible party, but these attempts were unsuccessful. There was not enough evidence to determine R1’s responsible party was not notified; therefore, the allegation was unsubstantiated.

An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report, and License Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received by the ED.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC9099 (FAS) - (06/04)

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