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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604441
Report Date: 02/23/2026
Date Signed: 02/24/2026 08:57:55 PM

Substantiated


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
01/28/2025 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 08-AS-20250128115727
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: 111DATE:
02/23/2026
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Adrian GuillenTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Neglect/Lack of supervision resulting in serious bodily injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with Administrator, Adrian Guillen, and explained the purpose of today’s visit.

Regarding the allegation that neglect and lack of care and supervision resulted in Resident 1 sustaining a fall and serious bodily injury, the investigation revealed sufficient evidence to support the allegation. Between August 2024 and January 2025, Resident 1 experienced approximately nine falls while residing at the facility. The majority of these incidents occurred in his bedroom, typically near his bed or recliner. According to his Physician’s Report, Resident 1 was non-ambulatory and required staff assistance for transfers. Resident 1 was identified as a fall-risk resident. Interviews conducted with multiple staff revealed that Resident 1 had a small bed rail installed upon admission; however, the bed rail was insufficient to prevent falls. The resident was not provided with a fall mat, call pendant, or other fall-prevention measures. Facility staff further stated that Resident 1 required two-person assistance for safe transfers. Due to ongoing staffing shortages, the facility only accommodated one-person-assist. LPA interviewed the facility Resident Services Director, who confirmed that the facility was aware of Resident 1's increased care needs and had discussed this with Resident 1's daughter on multiple occasions. Despite this awareness, no action was taken to relocate the resident to a facility capable of meeting his needs. On January 27, 2025, Resident 1 ate lunch in his room. At some point, his water spilled on the floor, and he subsequently slipped and fell, landing on his left side. Initially, he did not complain of pain; however, a few hours later, he began to experience significant discomfort.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2026
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 3
Control Number 08-AS-20250128115727
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2026
Section Cited
CCR
87464(f)(1)
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(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). The following requirement has not been met as evidenced by:
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The facility administrator will train all direct care staff on:fall prevention strategies, Proper transfer techniques, Monitoring high-risk residents, Documentation of changes in condition, Training to be completed by (date) and documented in staff files and send proof to LPA by POC date of 02/24/2026.
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The facility did not provide Resident 1 sufficient care and supervision, which lead to falls resulting in fracture/injury, which is an immedaite health, safety, or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 08-AS-20250128115727
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: 02/23/2026
NARRATIVE
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Staff called 911, and Resident 1 was transported to Sharp Hospital, where medical records confirmed an acute left femoral neck fracture. LPA interviewed Dr. Randall Baldassarre from Sharp Hospital. Dr. Baldassarre stated that the term “acute” refers to an injury occurring within a few days, and confirmed the injury was consistent with a fall. Although other causes could not be ruled out entirely, Dr. Baldassarre stated that a fall was the most likely cause, especially for an elderly individual. The investigation revealed that Resident 1's care plan listed him as one-person assist, but staff had determined after move-in that he required two-person assistance. The facility did not update the care plan accordingly and failed to take corrective action to ensure Resident 1's needs were met. The facility also did not terminate residency or relocate the resident to a higher-level-of-care setting, despite knowing it could not meet his supervision and transfer requirements. Based on interviews, record review, and corroborating documentation, the preponderance of evidence shows that the facility failed to provide adequate care and supervision. This failure resulted in a fall causing serious bodily injury. Therefore, the above allegation is found to be SUBSTANTIATED.


The following deficiencies are being cited (see LIC 9099D) from the California Code of Regulations, Title 22,
and the California Health and Safety Code. This incident is currently under review and a future civil penalty
may apply based on H&S Code section 1569.49(f). Failure to correct the deficiencies may result in additional
civil penalties. Exit interview conducted with Administrator Adrian Guillen, and appeal rights
provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3