Monarch Cottages La Jolla

Allegation investigated: - Staff did not provide two-person assist for resident transfer.

Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint investigation visit to deliver findings on the above . LPA was granted entry to the facility and met with Risa Jester, Executive Director, after identifying herself and explaining the reason for the visit. The Department’s investigation consisted of review of facility records, outside source records, and interviews of facility staff and outside sources. It was alleged that facility staff did not provide two-person assist for resident transfer. A review of facility records revealed thar Staff 1 (S1) did transfer Resident 1 (R1) without assistance. R1’s care plan requires a two-person transfer for the safety of R1 and staff members. The allegation is therefore Substantiated, and one (1) deficiency was cited for it per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Risa Jesterthe state’s words, verbatim · CDSS document, Mar 11, 2026 · control 08-AS-20210728124213

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility did not meet resident's hygiene needs.

Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint investigation visit to the facility to deliver findings regarding the above allegation. LPA was granted entry to the facility after identifying herself. LPA met with Karen Moran, LVN Cognitive Entrenchment Director and explained the reason for the visit. The Department’s investigation consisted of LPA observations, a review of facility and outside source records, and interviews of internal and outside sources. It was alleged that the facility did not meet resident's hygiene needs. Specifically, that the facility did not provide for or arrange for proper foot care resulting in Resident 1’s (R1) toenails being uncut and grown significantly beyond the ends of R1’s toes. The investigation determined through interviews and a review of internal and external documents that at the time of R1’s admission to the facility consent was given for R1 to receive podiatry care from an outside provider. Substantiatedthe state’s words, verbatim · CDSS document, Jan 12, 2026 · control 08-AS-20210402112310

Allegation investigated: Staff handled resident in a rough manner. Staff did not respond timely to resident’s call button. Facility did not provide adequate incontinence care for resident.

Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint investigation visit to the facility to deliver findings regarding the above allegations. LPA was granted entry to the facility after identifying herself. LPA met with Risa Jester, Executive Director and explained the reason for the visit. The Department’s investigation consisted of LPA observations, a review of facility and outside source records, and interviews of internal and outside sources. It was alleged that staff handled Resident 1 (R1) in a rough manner. The allegation was that a staff member pulled an item from a resident’s hand. There was no specific object identified in the allegation. Interviews with internal and external sources did not reveal any confirming evidence that R1 or any other resident was treated in a rough manner. This allegation is Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 29, 2025 · control 08-AS-20210913092229

Allegation investigated: Staff did not seek medical attention for resident

Licensing Program Analysts (LPAs) Arian Golbakhsh and Iby Strong conducted an unannounced visit to open a complaint investigation and delivered findings regarding the above mentioned allegation. LPAs were welcomed by, identified themselves to, and discussed the purpose of their visit to Executive Director Risa Jester. On 05/27/2025, the Department received a complaint allegation where it was alleged that a resident at the facility identified as (R1) sustained a fall and did not receive medical care. No timeline was provided in the complaint regarding when R1 had fallen. The Department’s investigation consisted of an unannounced facility visit, records review, and interviews with staff, residents, and outside sources. [Continued on LIC 9099-C] Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 4, 2025 · control 08-AS-20250527152121

Allegation investigated: Neglect/Lack of Supervision resulted in resident sustaining serious injury.

Licensing Program Analysts (LPA) Iby Strong and Arian Golbakhsh conducted an unannounced complaint visit to deliver findings in the above-mentioned allegation. LPAs met with Executive Director RIsa Jester and discussed the purpose of the visit. On June 13, 2023, Community Care Licensing (CCL) received a complaint alleging neglect/lack of supervision resulted in Resident 1 (R1) (R1 – see LIC811 Confidential Names List) sustaining serious injuries. According to R1’s Physician Report, R1 is diagnosed with a major neurocognitive disorder, is non-ambulatory, and has motor impairment/paralysis. R1’s Needs and Services Plan states R1 is a total assist with activities of daily living and a two person assist with bathing, washing and toileting. During investigation, the Department collected pertinent resident records as well as facility documentation and conducted interviews. According to the allegation, on an undisclosed date in May of 2023, R1 was being transported and dropped by an unknown sthe state’s words, verbatim · CDSS document, Jun 4, 2025 · control 08-AS-20230613182530

Allegation investigated: Staff did not follow infection control procedures

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced a follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Congnitive Enrichment Director Alicia Prichard. Throughout the investigation, the Department secured records and conducted interviews with external and internal sources. It was alleged staff did not follow infection control procedures. On 8/23/2024 it was reported to the Department Resident # 1 (R1) was diagnosed with an infectious disease and the facility was not following infection control procedures. Interviews with both internal and external sources confirmed R1 was diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA). Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 28, 2025 · control 08-AS-20240823095237

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.