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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426330
Report Date: 11/13/2023
Date Signed: 11/13/2023 12:51:03 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
11/06/2023 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20231106130652
FACILITY NAME:VISTA MONTANA SENIOR LIVINGFACILITY NUMBER:
336426330
ADMINISTRATOR:MARYANN KANEKOAFACILITY TYPE:
740
ADDRESS:155 N. GIRARD ST.TELEPHONE:
(951) 658-2274
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:120CENSUS: 75DATE:
11/13/2023
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Maryann Kanekoa Navarez, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not provide adequate supervision, resulting in a resident wandering away from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Administrator, Maryann Kanekoa Navarez, and informed her of the purpose for the visit.

A report was received by the Department alleging Resident One (R1) was found outside of the facility and did not know what their current location was. The investigation included staff/resident interviews, records review, and records collection. R1 was interviewed though could not provide a statement regarding the incident. Administrator Navarez was interviewed and reported she was notified on 11/05/2023 of R1 being out in the community on 11/04/2023. She stated the resident was picked up by staff and returned to the facility the same day without injuries. Facility staff were interviewed and reported the resident does not usually leave the facility on their own. It was reported no similar incidences have happened prior to 11/04/2023. R1's Physician's Report for Residential Care Facilities for the Elderly (RCFE) revealed R1 is able to leave the facility unassisted;
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
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-20231106130652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VISTA MONTANA SENIOR LIVING
FACILITY NUMBER: 336426330
VISIT DATE: 11/13/2023
NARRATIVE
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 however, an Assessment Tool completed on 03/01/2023, by a third-party agency, revealed R1 was observed to usually not be able to make decision, judgement frequently impaired/requires cues and supervision. In addition, the report stated R1 did not have symptoms of wandering at the time of the assessment. Administrator Navarez reported she has reached out to R1's case worker to have the individual re-evaluated. Therefore, based on records, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted; this report was reviewed with Administrator Navarez and a copy was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2