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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603589
Report Date: 06/19/2026
Date Signed: 06/19/2026 10:26:19 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
10/04/2022 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20221004155634
FACILITY NAME:MONTE VISTA VILLAGEFACILITY NUMBER:
374603589
ADMINISTRATOR:SUSAN BERWINFACILITY TYPE:
740
ADDRESS:2211 MASSACHUSETTS AVENUETELEPHONE:
(619) 465-1331
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:0CENSUS: 0DATE:
06/19/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Facility is CLosedTIME COMPLETED:
10:25 AM
ALLEGATION(S):
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9
Staff did not meet the resident's hygiene needs.
Staff did not assist the resident with medication management.
Staff did not transport the resident to medical appointments.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Tiffany Holmes concluded the complaint investigation regarding the above mentioned allegations. The facility is closed, reports mailed certified.

LPA Correia conducted a tour of the facility on 10/12/2022. It was alleged that the staff did not meet the resident's hygiene needs, the staff did not assist the resident with medication management and the staff did not transport the resident to medical appointments. Interviews revealed that the resident no longer lives at the facility and could not be interviewed. LPA was not able to conduct any staff or resident interviews due to the facility being closed. Outside sources were called with no return calls. Interviews with the Executive Director of the new facility revealed they do transport residents but only on Mondays, Wednesdays and Fridays. The residents get this info when they move in. They only drive the residents within a 12 mile radius. They are not allowed to take them to urgent care or the hospital because it is a liability. They will call 911 for the residents if they need to go but the residents or the family members don't want to pay for the ambulance ride. Interviews revealed the rules say there are 2 vehicles with 1 driver and they need to know 24 hrs prior to going somewhere so they can put it on the books. Interviews revealed the resident cannot be made to shower and if they refuse they will circle back and ask them again. Interviews revealed the staff have been trained on medication management and how to disperse medications and they disperse according to the doctors orders.

The investigation did not produce supporting evidence or supporting witness statements to substantiate staff did not meet the resident's hygiene needs, staff did not assist the resident with medication management and staff did not transport the resident to medical appointments. Based on the evidence obtained from interviews, the complaint allegation is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Due to the facility’s closure, no exit interview was conducted. A copy of this report, along with Licensee Rights (LIC 9058 03/22), were mailed via USPS certified mail to the last mailing address on file.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
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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