Monte Vista Village Senior Living

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.

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.

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.

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.

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.

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: Licensee did not protect resident Unlawful eviction Neglect resulted in resident on resident abuse

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 June 29, 2023 it was alleged licensee did not protect resident, unlawful eviction, and neglect resulted in resident on resident abuse. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 2, 2025 · control 08-AS-20230629152942

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.

Allegation investigated: Facility is not following proper Covid-19 infection control protocols.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver findings regarding the above-mentioned complaint allegation. LPA met with Executive Director (ED) Adrian Guillen, identified herself, and stated the purpose of the visit. The Department's investigation consisted of staff and resident interviews and records reviews, and a facility tour. It was alleged the facility did not follow proper COVID-19 infection control protocols. An interview with former Staff1 (S1) revealed they had worked in a unit of the facility where Resident1 (R1) resided and disclosed R1 tested positive for COVID-19. S1 revealed feeling sick the following day and believed to have contracted COVID-19 from R1. The interview with S1 also revealed staff did not put infection control precautions into place. S1 disclosed they had called out sick and was asked to return to take a COVID-19 test. S1 stated the test was administered by the Director of Maintenance (DOM) however, was never givethe state’s words, verbatim · CDSS document, Jul 15, 2025 · control 08-AS-20230227134000

Allegation investigated: Staff changed level of care for resident without a physicians assessment.

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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 15, 2025 · control 08-AS-20250423125647

Allegation investigated: Staff did not prevent financial abuse of resident.

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 Guillen, identified herself, stated the purpose of the visit. The Department’s investigation included staff interviews, facility and resident records reviews, and facility tour. On February 10, 2025, the Department received a complaint that alleged the Licensee did not prevent financial abuse of a resident in care. It was alleged Resident1 (R1) was financially abused by Resident2 (R2) who was allegedly R1’s roommate. R1 revealed they felt the roommate was trying to kill them by feeding them sweets that R1 was not supposed to eat due to their Diabetes for financial gain. A review of R1’s facility records revealed they were admitted to the facility on June 9, 2023, with a primary diagnosis of Diabetes and Hyperlipidemia. R1’s records also revealed they were diagnosed with a mood disorder. R1’s facility recorthe state’s words, verbatim · CDSS document, Jul 14, 2025 · control 08-AS-20250210162803

Allegation investigated: Licensee changed resident’s room without their consent. Licensee did not allow resident to use their own transportation provider.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude a complaint investigation. LPA Correia was greeted by Concierge Debra Kramer identified herself, stated the purpose of the visit, and met with Executive Director (ED) Guillen. The Department’s investigation included staff and resident interviews, and resident and outside source records reviews. It was alleged that facility staff transferred a resident to a different room at the facility without consent. On February 14, 2025, the Department received a complaint that alleged when Resident1 (R1) returned from a hospital stay found all their belongings had been transferred to a different room. An interview with R1 revealed they sustained a fall on June 22, 2024, resulting in a knee injury and hospital stay and upon return to the facility on approximately September 19, 2024, found staff had relocated all their belongings to a different room without their knowledge or consent. [Continued on LIC 9099C] *the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 08-AS-20250214162151

Allegation investigated: Staff are not assisting resident with obtaining medical care

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to deliver findings regarding the allegation mentioned above. LPA was allowed entry. LPA identified herself and disclosed the purpose of the visit and elements of the complaint to the Administrator. It was alleged that staff are not assisting Resident 1 (R1) with obtaining necessary medical care. The investigation consisted of a tour of the facility and collecting resident records, and interviews with the Administrator, resident, and observations. The Administrator stated that the facility has a longstanding policy limiting transportation services to a 10-mile radius. While R1 was aware of this policy, the facility had previously made exceptions to accommodate R1’s medical needs by providing transportation to Kaiser in Kearney, which exceeded the 10-mile limit. Continued on 9099C Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 2, 2025 · control 08-AS-20250225144112

Allegation investigated: Facility did not provide a higer level of care for resident.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude a complaint investigation and render findings. LPA Correia was greeted by Concierge Debra Kramer, identified herself, stated the purpose of the visit, and met with Executive Director (ED) Adrian Guillen and Resident Service Director (RSD) Monica Maldonado. The Department’s investigation included staff and outside source interviews and resident and outside source records reviews. It was alleged the facility did not provide a higher level of care for Resident1 (R1). A review of resident records revealed R1 was admitted to the facility on January 16, 2016, at the time of admission records showed R1 was independent with all Activities of Daily Living skills (ADLs) and moved into the independent unit of the facility. Review of records dated 2020, revealed R1 was still determined independent and required no assistance with ADLs. On December 10, 2024, a facility records revealed R1 notified facility stafthe state’s words, verbatim · CDSS document, Jun 19, 2025 · control 08-AS-20250612162956

Allegation investigated: Staff did not ensure that facility is delivering hot water.

Licensing Program Analyst (LPA) Correia conducted an unannounced visit to deliver the investigative finding regarding the above-mentioned allegation. LPA was met by the front Receptionist Hubbard, identified herself, and was granted entry into the facility. LPA then met with Executive Director (ED) Guillen, who was explained the purpose of the visit. The Department's investigation consisted of staff and resident interviews and a facility tour. On September 6, 2024, the Department received a complaint that alleged the faucets in the women’s restroom sinks located in the facility’s auditorium, which was temporarily used as the dining area for residents in care, were not supplying hot water. An interview with the ED revealed that the facility was building a new memory care unit that resulted in a temporary relocation of the residents' dining area. Interviews conducted with residents in care did not have knowledge of the faucets without hot water in the women’s auditorium restroom. Howeverthe state’s words, verbatim · CDSS document, Mar 12, 2025 · control 08-AS-20240906100527

Allegation investigated: Staff do not ensure that the facility is maintained in good repair. Staff do not ensure that facility is maintained at a comfortable temperature for residents. Staff do not ensure that facility is maintained sanitary.

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced subsequent complaint visit regarding the above-mentioned allegations. LPA was met by, identified herself to, and discussed the purpose of the visit with Director Adrian Guillen. Concierge Kathryn Hubbard later joined the visit to sign documents. The Department's investigation consisted of record review, interviews with facility staff and residents, and included LPA observations. It was alleged that the facility is not maintained in good repair. During LPA tour of lounge restrooms it was demonstrated the toilets were not working. Resident and staff interviews confirmed that the toilets were not working. Staff indicated that the bathroom had new plumbing but a piece of metal was lodged in the plumbing pipes and backing up water for the last three months so the bathrooms were closed. Substantiatedthe state’s words, verbatim · CDSS document, Mar 10, 2025 · control 08-AS-20241220150424

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 wrongfully evicted a resident. Licensee did not provide a refund. Staff did not report an injury to a resident’s responsible party.

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Adrian Guillen. Throughout the investigation, the Department secured records and conducted interviews with external and internal sources. It was alleged the facility wrongfully evicted a resident. It was reported to the Department the facility forced Resident # 1(R1)’s family and responsible party to move R1. The facility allegedly assessed R1, determined the level of care had increased, and notified the responsible party fees would be increased. The facility allegedly refused to discuss a care plan with R1’s family and R1’s hospice agency. (See LIC 9099C for continuation of report.) Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 13, 2025 · control 08-AS-20240626104728

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: Licensee did not ensure facility grounds were free of pest Staff spoke to resident in an inappropriate manner

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Adrian Guillen. On September 12, 2024, Community Care Licensing (CCL) received a complaint alleging licensee did not ensure facility grounds were free of pest and Staff 1 (S1) spoke to Resident 1 (R1) in an inappropriate manner. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegation, there have been spiders, cockroaches and flees observed at the facility. Interview with Executive Director revealed that facility has a contract with a pest control company and have regular visits. Interview with staff present corroborated that a pest control company is present periodically. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 10, 2024 · control 08-AS-20240912085819

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: Licensee did not comply with the admission agreement

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Adrian Guillen. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the Licensee did not comply with the admission agreement, specific to laundry services. Review of a random sampling of residents’ admission agreements revealed that sometime between 2021 and 2022, the facility began using a different version of their admission agreement. Admission agreements signed prior to the change indicated that the facility provided personal laundry services for a fee and made washing and drying machines available for resident use. Review of the facility’s rate list as of 2021, revealed that the facility did not have a monetary charge for adthe state’s words, verbatim · CDSS document, May 6, 2024 · control 08-AS-20240228112500

Allegation investigated: Unlawful eviction. Staff did not provide medical attention for resident. Staff did not treat resident with dignity.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude an investigation regarding the above-mentioned allegation. LPA was greeted by the Receptionist, Andrea Maldonado-Odgers, identified herself, and met with Executive Director (ED) Guillen and stated the purpose of the visit. The Department's investigation included facility records reviews and staff and outside source interviews. It was alleged facility staff did not seek medical attention to a Resident 1 (R1) in care after sustaining a fall. A facility and resident records review revealed on December 28, 2023, R1 sustained an unwitnessed fall at the facility and upon staff discovering that R1 had sustained a fall they called 911 and R1 was transferred to the hospital. Records also revealed on January 4, 2024, R1 left the hospital against medical advice and returned to the facility. Unfoundedthe state’s words, verbatim · CDSS document, Mar 15, 2024 · control 08-AS-20240308160149

Allegation investigated: Unlawful eviction Staff not providing assistance resulting in multiple falls

Licensing Program Analyst (LPA), Mark Mandel conducted an unannounced visit to follow-up on a complaint investigation regarding the above-mentioned allegations. LPA was granted entry and met with Resident Services Director, Monica Maldonado. LPA stated the purpose of the visit and discussed the elements of the complaint with Director Maldonado. LPA delivered the investigative findings to Director Maldonado. Today's visit consisted of resident and staff interviews and observing residents in care. On 01/05/2024, the Department received a complaint alleging that facility staff processed an unlawful evicition. The Department's investigation consisted of facility visits, record reviews and interviews with staff, residents and outside sources. A review of records revealed Resident 1 (R1) was admitted to the facility on 06/29/2023 and observations and interviews with staff and R1 revealed R1 still lives at the (Cont. on LIC9099) Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 9, 2024 · control 08-AS-20240105095151

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: Unqualified staff dispensing medication. Staff pre-poured medications. Staff did not assist with medication as prescribed. Lack of supervision resulted in resident AWOL. Staff did not meet resident(s) incontinence needs. Staff did not meet resident(s) basic needs. Staff did not treat resident(s) with dignity.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Monica Maldonado, Resident Services Director. On 3/9/23 it was alleged that unqualified staff dispensed medication, staff pre-poured medications, staff did not assist with medication as prescribed, lack of supervision resulted in resident AWOL, staff did not meet residents' incontinence needs, staff did not meet residents' basic needs, and staff did not treat residents with dignity. The Department’s investigation consisted of unannounced facility visits, review of relevant records, interviews with facility staff, residents, and outside sources. Regarding the allegation, "Unqualified staff dispensing medication", it was alleged that the Medication Technicians "Med Techs" did not receive the required amount of training hours before assisting residents with medication. (Continued on Lthe state’s words, verbatim · CDSS document, Dec 26, 2023 · control 08-AS-20230309131053

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