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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604441
Report Date: 07/15/2025
Date Signed: 08/22/2025 03:11:37 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
04/23/2025 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20250423125647
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:
07/15/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director (ED) GuillenTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff changed level of care for resident without a physicians assessment.
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 (ED) Adrian Guillen, identified herself, and stated the purpose of the visit.

The Department’s investigation included staff and outside source interviews and a resident record review.

On April 23, 2025, the Department received a complaint that alleged facility staff changed Resident’s 1 (R1’s) level of care at the facility without being reassessed by a Physician. A review of R1’s records revealed they were admitted to the facility on February 28, 2021, with Primary Diagnoses of Hypertension, Hyperlipidemia, Cerebral Vascular Accident, GERD, and Mild Cognitive Impairment (MCI).

[Continued on LIC 9099C]

*This is an amended version of the original report delivered 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-20250423125647
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: 07/15/2025
NARRATIVE
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[Continuation of LIC 9099]

An interview with the Residential Service Director (RSD) disclosed they notified R1’s Power of Attorney (POA) that R1 was displaying increased behaviors, subsequently R1 was taken to a Physician for a reassessment. Based on the reassessment signed and dated April 01, 2025, revealed R1 was prescribed additional medications, and was unable to self medicate, subsequently facility staff determined R1 required a higher level of care. An interview with Outside Source1 (OS1) revealed that the facility had always provided medication management to R1 since they moved in and there was no difference in care being provided to support the increase in price.

The interview with OS1 also revealed not being notified regarding the reassessment and increase in level of care due to medication management and OS1 believed R1 was able to self medicate with their assistance. In addition, OS1 disclosed R1 had an outside agency come to the facility daily to provide R1 assistance. However, the RSD disclosed and a record review corroborated, it was OS1 that took R1 to be reassessed, and it was determined by the reassessment that R1's increase in behaviors required an increase in a number of medications which required additional staff time, and a higher level of care was appropriate to meet R1’s needs. An additional record review, dated April 25, 2025, revealed that OS1 had R1 reassessed again by their PCP and was deemed able to self medicate. Subsequently an additional report (issued by the same physician that declared R1 able to self medicate on April 25, 2025, as previously mentioned) that was signed and dated on June 17, 2025, to the contrary of their initial report, revealed R1 was not able to self medicate and their POA would not provide assistance.

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 Rights (LIC 9058), will be provided. The signature below confirms receipt of the reports

*This is an amended version of the original report delivered 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