374604441-7-15-2025-08-AS-APAO-DJW6DN-20250724204325

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604441
Report Date: 07/11/2025
Date Signed: 07/15/2025 08:20:13 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
02/14/2025 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20250214162151

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:	07/11/2025
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Executive Director (ED) Adrian Guillen		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Licensee changed resident’s room without their consent.
Licensee did not allow resident to use their own transportation provider.

INVESTIGATION FINDINGS:

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

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

It was alleged that facility staff transferred a resident to a different room at the facility without consent. On February 14, 2025, the Department received a complaint that alleged when Resident1 (R1) returned from a hospital stay found all their belongings had been transferred to a different room. An interview with R1 revealed they sustained a fall on June 22, 2024, resulting in a knee injury and hospital stay and upon return to the facility on approximately September 19, 2024, found staff had relocated all their belongings to a different room without their knowledge or consent.

[Continued on LIC 9099C]

*This is an ammended version of the original report date July 11, 2025.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025

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-20250214162151

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: 07/11/2025

NARRATIVE

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[Continuation from LIC 9099]

Further review of facility records revealed between June 4, 2024, and June 25, 2024, there were several emails between R1 and Facility Management regarding issues R1 had with their current room, and they wanted to change rooms. On June 18, 2024, prior to the fall, R1 had sent an email stating their wheelchair broke and they were unable to walk due to a wound on the bottom of their foot, and they were told not to apply pressure on their foot to avoid an infection. R1’s email indicated a request to move to assisted living and paying for assisted living would not be a problem. Records and interviews revealed R1 was relocated to room 17F that is in a unit where more care is provided. On June 24, 2024, during the move, R1 sent an additional email notifying that they tested positive for COVID-19, and the fall they sustained on June 22, 2024, did not result in a fracture of their knee, but it was still very painful and required a brace. R1 requested staff to allow a close friend to enter both their apartments including 17F (Assisted Living) and unit 7b (Independent Living) to retrieve some of their belongings, while recovering in a Skilled Nursing Facility (SNF).

Additionally, R1’s facility records revealed they signed and dated a contract at their time of admission on April 29, 2024. The contract included a clause regarding substitute apartments that states in the event a change of room is required for the safety of the residents directly related to state regulation and/or liability risk we may substitute your apartment to another to comply with any law or lawful order authorized of any authorized public official, or for any other reasonable purpose, as determined by us. We will make reasonable accommodation with respect to your preferences concerning your apartment. We will provide you with thirty (30) days’ written notice before substituting your apartment, unless you agree with the request, it is required to fill a vacant bed, or it is necessary due to an emergency.

A facility record review dated June 18, 2024, revealed R1 resided in room 17F. However, on September 03, 2024, facility records revealed R1’s room was labeled O/C, and a review of the same facility record type dated September 30, 2024, disclosed R1’s room number was 17L and a new resident (R2) resided in 17F. An interview with the ED revealed R1 had given a verbal agreement to move their room while they were in the SNF. An email sent by R1, dated November 14, 2024, revealed R1 acknowledged being notified by the ED about the change in room while in the hospital, however stated they were not feeling well and could not remember at the time they had agreed at the time the complaint was filed.

[Continued on LIC 9099C]

*This is an amended versions of the original complaint delivered on July 11, 2025.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250214162151

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: 07/11/2025

NARRATIVE

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[Continuation of LIC 9099C]

It was also alleged that the Staff Management required R1 to take their contracted transportation agency and was told they were not permitted to use their own. An interview with ED disclosed that was a false statement and the facility has transportation available for residents in care if needed but they don’t have to use it. A facility record review revealed transportation (without an escort) is made available for specific activities but there is nothing in the contract that binds a resident to use the facility's transportation service. Interviews conducted with residents in care revealed staff had never required them to use the facility’s transportation services. Interview conducted with residents in care revealed staff had never required them to use the facility’s transportation services.

Based on staff interviews and facility and resident records reviews the allegation was determined to be UNSUBSTANTIATED, an unsubstantiated finding means there was not a preponderance of evidence to prove the violation occurred.

An exit interview was conducted with the ED and a copy of the report and Licensee Rights (LIC 9058) were provided. The signature below confirms receipt of the reports.

*This is an amended version of the original report delivered on July 11, 2025.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025

LIC9099 (FAS) - (06/04)

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