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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426330
Report Date: 04/11/2022
Date Signed: 08/29/2025 10:35:51 AM

Unsubstantiated


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:
02:32 PM
MET WITH:Raquel Montes, AdministratorTIME COMPLETED:
02:33 PM
ALLEGATION(S):
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9
Resident developed pressure injuries while in care.
Medical treatment was not sought for resident in a timely manner.
Resident sustained an unwitnessed fall while in care.
INVESTIGATION FINDINGS:
1
2
3
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5
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9
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12
13
*This is an amended version of an original report dated 04/11/2022.
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 allegations. LPA met with Administrator Raquel Montes and explained the purpose of the visit. The following allegations were determined to be UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Regarding the allegation, "Resident developed pressure injuries while in care", interviews with staff revealed R1 was in the process of admission. R1 was at the facility during the initial physical assessment by staff. Staff observed pressure injuries and declined to admit. Staff called and had R1 transferred to the hospital. The phone number provided for R1 no longer belonged to R1 and the LPA was unable to interview R1. Staff were not aware of any responsible party for R1.




Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
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 2
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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*This is an amended version of an original report dated 04/11/2022.

Regarding the allegation, "Medical treatment was not sought for a resident in a timely manner", interviews conducted did not reveal details regarding this allegation. It was alleged that it was in reference to R9. LPA obtained a copy of the Unusual Incident/Injury Report for R9 dated 03/23/2022 and it revealed R9 was found on the floor. It further revealed staff called for an ambulance when R9 was found on the floor and R9 was transported to the hospital. LPA obtained a copy of the Unusual Incident/Injury Report for R9 dated 03/29/2022 and it revealed R9 had a follow up medical appointment and during that visit, the physician ordered R9 to be sent out via non-emergency to be further evaluated. Resident had been unable to manage their diagnosis. R9 no longer resides at the facility and LPA was unable to obtain contact information, therefore R9 was not interviewed.

Regarding the allegation, "Resident sustained an unwitnessed fall while in care." R9 no longer resides at the facility and LPA was unable to obtain contact information therefore R9 was not interviewed. A review of R9's Physician Report dated 02/10/2022, R9 was non-ambulatory and was able to bathe, dress/groom and care for own toileting needs. The report also indicated "no" under motor impairment/paralysis.

An exit interview was conducted with Ms. Montes and a copy of this report was provided along with copies of the LIC811, and LIC811-C.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
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: 2 of 2