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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426330
Report Date: 08/20/2025
Date Signed: 08/20/2025 10:28:47 AM

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
10/24/2022 and conducted by Evaluator Debbie Palacios
COMPLAINT CONTROL NUMBER: 18-AS-20221024110115
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: 88DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria Forkrud, AdministratorTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Resident sustained multiple bruises while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Debbie Palacios conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Debbie Palacios met with Administrator Maria Forkrud and explained the reason for the visit.

On 10/24/2022, the Riverside Adult and Senior Care Regional Office (RO) received a complaint regarding a Neglect/Lack of Supervision Allegation. Resident #1 (R1) was brought to the hospital on 10/16/2022 with multiple bruises to legs and face that were inconsistent with a fall.

According to the facility file documents reviewed, R1 was admitted to the facility on 09/01/2021. Per the review of R1’s Physician’s Report, the primary diagnosis includes Muscle Weakness, History of Falls, and Alzheimer’s. R1’s Secondary diagnosis includes Abnormal and Unsteady Gait, Fracture of Right Patella, and Unsteady on feet. R1 is listed as ambulatory. R1’s Needs and Services Plan was completed on 09/02/2021.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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-20221024110115
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: 08/20/2025
NARRATIVE
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The Needs and Services Plan documents, “R1 ambulates independently, is alert and able to make needs known. R1 is able to transfer to and from bed and chair, needs help toileting, dressing and bathing.”R1’s Individual Service Plan was updated on 07/14/2022. The plan documents R1’s diagnosis as Mild Cognitive Impairment and requires reminders from staff. R1 requires assistance with mobility/ambulation, and the plan states “RCFE staff will continue to reinforce fall precautions and will assist R1 in mobility or ambulation as needed, per patient’s request.” A review of the Special Incident Reports (SIRs) submitted by the facility revealed the following: On 09/29/2022, at approximately 11:55pm, while doing rounds, care staff found R1 on the floor in their room with a big bump on forehead.
911 was called and R1 was transported to the hospital. On 10/02/2022, the facility shift report notes R1 had a fall but was not hurt. On 10/16/2022, the SIR documents R1 had a fall in the hallway and sustained an injury to their forehead, and it was bleeding. 911 was called and R1 was transported to the hospital. On October 16, 2022, at 5:33am, R1 was transported by ambulance to the hospital emergency department (ED) with a head injury from a fall. Per the EMS report, R1 had an unwitnessed fall at the facility and was found in the hallway by staff.
R1 was noted to have a hematoma to the forehead. Per EMS, R1 stated R1 thought R1 was in R1’s room and was trying to get up when R1 fell. R1 denied loss of consciousness, neck pain or back pain. No other complaints were reported at this time. R1’s initial diagnosis included traumatic head injury with multiple lacerations, traumatic injury of head with hematoma of scalp, and facial hematoma.
At 7:17am, the ED notes documented, R1 has a large hematoma to forehead with bleeding controlled and bruising around left orbital (eye) and left cheek. R1 reports that R1 had been falling more often. R1 reports slight soreness to area but recently got an IV. R1 has a wound on the right shin in the late stages of healing. R1 with bruising in multiple stages of healing, history of recent frequent falls. R1’s assessment also documented a urinary tract infection (UTI). On 10/21/2022, R1 was discharged back to the facility with an order of outpatient physical therapy for continued rehabilitation of functional mobility.

Upon returning from the hospital on 10/21/2022, staff ordered Home Health Services, a hospital bed, and reassured R1’s resident representative that the staff would increase the frequency of checks and encourage R1 to utilize the walker when ambulating. Staff assessed R1 after each incident and notified 911 in a timely manner.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20221024110115
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: 08/20/2025
NARRATIVE
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The information obtained during the Department’s investigation did not sufficiently support the allegation. While R1 did sustain falls which resulted in multiple bruises, the investigation did not provide sufficient evidence to substantiate neglect/lack of supervision. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of this report issued.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3