374604441-6-20-2025-08-AS-APAO-DJ6MU9-20250701095447

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604441
Report Date: 06/19/2025
Date Signed: 06/20/2025 02:58:20 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
06/12/2025 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20250612162956

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: 103	DATE:	06/19/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Executive Director Adrian Guillen		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility did not provide a higer level of care for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude a complaint investigation and render findings. LPA Correia was greeted by Concierge Debra Kramer, identified herself, stated the purpose of the visit, and met with Executive Director (ED) Adrian Guillen and Resident Service Director (RSD) Monica Maldonado.

The Department’s investigation included staff and outside source interviews and resident and outside source records reviews.

It was alleged the facility did not provide a higher level of care for Resident1 (R1). A review of resident records revealed R1 was admitted to the facility on January 16, 2016, at the time of admission records showed R1 was independent with all Activities of Daily Living skills (ADLs) and moved into the independent unit of the facility. Review of records dated 2020, revealed R1 was still determined independent and required no assistance with ADLs. On December 10, 2024, a facility records revealed R1 notified facility staff they were having dizzy spells and the facility activated 911.
[Continued on LIC9099C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

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-20250612162956

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: 06/19/2025

NARRATIVE

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[Continuation of LIC 9099]

A staff interview and facility record review also revealed R1’s companion notified the facility that R1 had sustained a fall during an outing on that same day, December 10, 2024. A review of Outside Source1 (OS1) records dated December 11, 2024, disclosed R1’s fall resulted in a Traumatic Subdural Hematoma causing a significant change in condition.

Upon discharge from the hospital and return to the community on December 11, 2024, R1 started to receive services from an outside agency. An additional interview conducted with Outside Source2 (OS2) corroborated R1 received services from an outside agency from 1:00pm to 5:00pm every day and is in process of obtaining additional services for R1. Interviews and record reviews revealed on March 28, 2025, facility management and R1’s Responsible Parties (RPs) met regarding R1’s need for a higher level of care, including medication management and fall prevention. Facility record reviews also confirmed facility Management is actively trying reach out to R1’s Primary Care Physician (PCP) for an updated Physician’s Report, and trying to work with R1’s RP to ensure R1 is receiving the proper level of care.

Based on record reviews and interviews with facility staff and outside sources the above-mentioned allegation was determined to be Unsubstantiated. An Unsubstantiated finding means the preponderance of evidence to prove the violation occurred was not met.

An exit interview was conducted with E.D. Guillen, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided. Signature below confirms receipt of the reports.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC9099 (FAS) - (06/04)

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