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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604441
Report Date: 04/10/2026
Date Signed: 04/10/2026 05:19:05 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
11/22/2024 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20241122162544
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: 113DATE:
04/10/2026
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Executive Director Adrian GuillenTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Licensee did not ensure resident had clean bedding.
Licensee’s staff did not treat the resident with dignity.
Licensee did not keep the facility free of insects.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Adrian Guillen.

On November 22, 2024, Community Care Licensing Division (CCLD) received a complaint alleging that Licensee did not ensure Resident #1 (R1) had clean bedding, Licensee’s staff did not treat a resident with dignity, and Licensee did not keep the facility free of insects.

The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, photo evidence review, LPA observations, and record review.

(Continued on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2026
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 6
Control Number 08-AS-20241122162544
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: 04/10/2026
NARRATIVE
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(Continued from LIC9099)
Regarding the allegation that Licensee did not ensure R1 had clean bedding. More specifically, a stained blanket was observed by the Reporting Party on 09/09/2024. Department interviews with Staff #1 and Staff #2 revealed acknowledgment that the facility’s linen inventory included worn or stained items. Department resident interviews revealed that multiple residents reported bedding and towels that were stained, worn, or frayed. Department LPA observations revealed worn linens in circulation during the visit. Photo evidence presented by reporting party showed visibly stained bedding.

Regarding the allegation that Licensee’s staff did not treat resident with dignity. More specifically, a caregiver allegedly removed a spoon from a resident and stated, “You’re done now,” abruptly ending the resident’s meal. Department resident interviews revealed a credible eyewitness account confirming that the incident occurred and describing additional instances of abrupt or cold interactions by the same caregiver.

Regarding the allegation that licensee did not keep the facility free of insects. More specifically, residents and photographs showed food left out after meal service, and multiple residents reported mosquitos, ants, and spiders inside Building 17 as well as main dinning area. Photo evidence supported that food remained out long after meals in November 2024. Department interviews with Staff #4 revealed awareness of mosquitos and use of a UV insect device in at least one room. Department resident interviews revealed repeated observations of mosquitos, ants, spiders and flies over time. Department LPA observations confirmed exterior doors to Building 17 were propped open and food remnants were left out, contributing to pest presence. LPA observation on 4/10/2026 Blue light pest control traps on the walls of the main dining area. Observation also revealed large sliding glass doors that lead into the common/dinning building and may contribute to insects entering the building.

Based on relevant interviews, LPA observations, records review, and photo evidence, the preponderance of evidence has been met that the above violations occurred and are therefore SUBSTANTIATED. Deficiencies are cited per California Code of Regulations, Title 22 (see attached LIC 9099D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20241122162544
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: 04/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/08/2026
Section Cited
CCR
87303(a)
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87303(a) The facility shall be clean, safe, sanitary and in good repair at all times.... for the safety and well-being of residents, employees and visitors. .This requirement is not met as evidenced by:
Based on observation and interviews, the licensee did not ensure the facility was
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Licensee stated they will remove all damaged linens, purchase replacements, and implement monthly linen checks by the POC due date.
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clean, safe, and sanitary for multiple residents in Building 17, as LPA observed stained and torn linens, insects inside the building, food left out, and exterior doors propped open, which poses a potential health and safety risk to persons in care.
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Type B
05/08/2026
Section Cited
CCR
87468.1(a)(1)
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87468.1(a)(1) Residents shall be accorded dignity in their personal relationships with staff, residents, and other persons.
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Licensee stated they will conduct training on dignity and respect during mealtime practices and complete dining room spot checks by the POC due date.
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Based on interviews, the licensee did not ensure dignity was accorded to 1 out of 1 resident in care (R1) when staff ended the resident’s meal by removing the spoon while the resident was still eating, which poses a personal rights risk.
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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: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
11/22/2024 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20241122162544

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: 113DATE:
04/10/2026
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Executive Director Adrian GuillenTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Licensee neglect, resulting in resident skin injury.
Licensee did not meet resident’s incontinence care need.
Licensee did not meet resident’s dressing/bathing need.
Licensee did not accommodate resident’s dietary preferences.
Licensee did not provide resident needed support with activities.
Licensee did not give resident medication as prescribed.
Licensee did not maintain custody/control of a centrally stored medicine.
Licensee did not allow resident to select their own pharmacy.
Licensee’s staff lacked good health necessary to perform job tasks.
Licensee’s staff lacked skill needed to communicate with residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Adrian Guillen.

On March 5, 2026, CCLD received a complaint alleging that above mentioned alligations.The Department’s investigation included unannounced visits, interviews with staff and residents, photo review, and records review.

Regarding the allegation that licensee neglect resulted in a skin injury to R1, Department interviews with staff revealed no reports of wound development and no wound documentation. Department records review revealed no wound care notes. Department LPA observations revealed no active wound during the visit. Photo evidence confirmed a wound existed but did not establish neglect as the cause.
(Continued on LIC9099)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20241122162544
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: 04/10/2026
NARRATIVE
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(Continued from LIC9099)

Regarding the allegation that licensee did not meet R1’s incontinence care needs, Department interviews with staff revealed no double padding practices, and residents did not report issues with their own care. Department records review revealed documentation did not indicate inadequate incontinence care. Photo evidence showed saturated items but lacked context linking the condition to facility practice.

Regarding the allegation that dressing/bathing needs were unmet, Department interviews with staff and residents revealed consistent showering practices, and records review revealed shower logs indicating missed care. Interviews with Residents did not indicate concerns with dressing or bathing.

Regarding the allegations related to dietary preferences, activities, medication administration, centrally stored medications, pharmacy selection, staff health, and staff communication ability, Department interviews with staff revealed no confirmed violations; Department resident interviews revealed no consistent concerns; Department records review revealed no documentation supporting the allegations; Department LPA observations revealed no concerns.

Based on interviews, direct LPA observations, and records review, the preponderance of evidence does not exist to prove that the alleged violations occurred; therefore these allegations are UNSUBSTANTIATED.

An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20241122162544
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: 04/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2026
Section Cited
CCR
87464(f)(2)
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Basic Services. Basic services shall at a minimum include: Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services. This requirement is not met as evidenced by:
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Administrator stated pest control is involved and will continue. In addition, administrator has called a complany to possibly install fans at openings/sliding glass doors at the main dining area of the facility. Administrator has provided the pest control recepits to LPA.
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Based on observations and interviews the licensee did not provide safe and healthful living accommodations for 9 out of 9 residents (R1-R9), which poses a health and safety 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: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6