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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604441
Report Date: 07/14/2025
Date Signed: 08/06/2025 07:52:40 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
02/10/2025 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20250210162803
FACILITY NAME:MONTE VISTA VILLAGE SENIOR LIVINGFACILITY NUMBER:
374604441
ADMINISTRATOR:ADRIAN GUILLENFACILITY TYPE:
740
ADDRESS:2211 MASSACHUSETTS AVENUETELEPHONE:
(619) 465-1331
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:219CENSUS: 103DATE:
07/14/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Executive Director (ED) GuillenTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not prevent financial abuse of 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 Executive Director Guillen, identified herself, stated the purpose of the visit.

The Department’s investigation included staff interviews, facility and resident records reviews, and facility tour.

On February 10, 2025, the Department received a complaint that alleged the Licensee did not prevent financial abuse of a resident in care. It was alleged Resident1 (R1) was financially abused by Resident2 (R2) who was allegedly R1’s roommate. R1 revealed they felt the roommate was trying to kill them by feeding them sweets that R1 was not supposed to eat due to their Diabetes for financial gain.

A review of R1’s facility records revealed they were admitted to the facility on June 9, 2023, with a primary diagnosis of Diabetes and Hyperlipidemia. R1’s records also revealed they were diagnosed with a mood disorder. R1’s facility records revealed at the time of admission R1 was independent and did not require assistance with Activities of Daily Living skills (ADLs).

[Continued on LIC 9099C]

*This is an amended version of the original report delivered on July 15, 2025.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
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 08-AS-20250210162803
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: 07/14/2025
NARRATIVE
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[Continuation of LIC 9099]

An additional review of R1’s records revealed they had been sent to the hospital on several occasions for behavioral issues including suicidal thoughts. R1’s facility records dated October 8, 2024, revealed they underwent a reassessment that showed R1 required moderate interventions, redirection, and status checks. On October 8, 2024, the reassessment added status checks to their care plan. An interview conducted with the Residential Service Director (RSD) on July 11, 2023, revealed R1 had severe mental health issues, never had a roommate, and everyone at the facility had private rooms unless they were a couple. The RSD also revealed that R1 was fixated on their roommate (referred to as R2) from their previous placement who R1 believed was trying to kill them by feeding them sweets (R1 is Diabetic) after R1 had put R2 in their (R1's) trust. A review of facility records corroborated the RSD’s statement regarding R1 having a private room. An interview with the Executive Director (ED) and a facility tour corroborated the information provided by the RSD.

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. Signature below confirms receipt of the reports.

*This is an amended version of the original report delivered on July 15, 2025.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2