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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426330
Report Date: 04/11/2022
Date Signed: 04/11/2022 03:51:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/04/2022 and conducted by Evaluator Jesse Gardner
COMPLAINT CONTROL NUMBER: 18-AS-20220404101121
FACILITY NAME:VISTA MONTANA SENIOR LIVINGFACILITY NUMBER:
336426330
ADMINISTRATOR:RAQUEL MONTESFACILITY TYPE:
740
ADDRESS:155 N. GIRARD ST.TELEPHONE:
(951) 658-2274
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:120CENSUS: 63DATE:
04/11/2022
UNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Raquel Montes, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Residents are not provided a safe environment while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility unanounced in order to deliver findings into an investigation of a complaint of the above allegation. LPA met with Administrator Raquel Montes (S1) and explained the purpose of the visit.

During today's visit, LPA interviewed three residents (R1, R2, R3) and one staff (S1). At the conclusion of the interviews, it was determined that the above allegation, "Residents are not provided a safe environment while in care" was deemed to be SUBSTANTIATED due to the residents rooms being kept locked on the outside, with one resident R4 needing assistance getting out of bed with a locked door. A Type A citation was issued, along with an immediate $500 civil penalty which was noted on the LIC421IM.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
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 18-AS-20220404101121
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VISTA MONTANA SENIOR LIVING
FACILITY NUMBER: 336426330
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/12/2022
Section Cited
CCR
87203
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FIRE SAFETY: All facilities shall..conformity with..regulations..State Fire.. protection of life and..against fire...This requirement is not being met as evidenced by:
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Licensee agrees to adhere to guidelines of the state marshall by changing all doors so that they cannot be locked. Licensee agrees to provide a memoradum of understanding of the regulation by POC date.
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Based on observation, LPA noticed several locked exterior doors. This is an immediate health and safety and 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: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20220404101121
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VISTA MONTANA SENIOR LIVING
FACILITY NUMBER: 336426330
VISIT DATE: 04/11/2022
NARRATIVE
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An exit interview was discussed with Ms. Montes and a copy of this report was provided along with a copies of the LIC9099-D, LIC421IM, LIC811, and Appeal Rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3