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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426330
Report Date: 12/16/2025
Date Signed: 12/16/2025 11:04:08 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
05/30/2024 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 18-AS-20240530120048
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: 84DATE:
12/16/2025
UNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Maria ForkrudTIME COMPLETED:
11:12 AM
ALLEGATION(S):
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Staff do not ensure that a resident's needs are being met.
Staff did not assist resident with arranging medical care.
INVESTIGATION FINDINGS:
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On December 16, 2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent visit to deliver findings regarding the above allegations. LPA Richard met with the Administrator Maria Forkrud (A1), and the purpose of the complaint was explained. LPA and the Administrator toured the facility.

The Investigation consisted of the following: On 6/7/2024, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to investigate the allegations listed above. LPA met with General Manager (GM) Raquel Montes, who was informed of the purpose of the visit. On December 11, 2025, Licensing Program Analyst (LPA) Antonine Richard reviewed and received the following documents: the Resident Roster (dated12/10/21), the Staff Roster (dated12/02/25), the Admission Agreements (dated 09/18/20) for Residents #1 (R1), R1 face sheet (dated 08/10/2021). Physician Report (dated 03/29/24), for R1. LPA Richard also conducted interviews with five residents (R2-R6), five staff members (S1-S5), and the administrator (A1).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
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-20240530120048
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: 12/16/2025
NARRATIVE
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Allegation #1: Staff do not ensure that the resident’s needs are met.

The allegation alleged that the resident, who arrived at the hospital, appeared to be malnourished, unkempt, malodorous, and having fecal matter stuck to him on a soiled diaper and frail. On December 11, 2025, the Licensing Program Analyst (LPA) interviewed the Administrator (A1), who denied the allegation of malnutrition and stated that the facility provides three meals a day along with snacks between meals. A1 emphasized that no residents could be malnourished. The resident in question, Resident #1 (R1), has expressed a desire not to be touched.

On the same day, the LPA interviewed five staff members (S1-S5), all of whom also denied the allegation. They confirmed that the facility offers adequate portions of food to all residents and provides an optional menu for those who do not want what is currently being served. It was noted that R1 prefers not to be touched by caregivers, except for one specific staff member, who is making efforts to assist R1 with showering and changing clothes whenever R1 is willing.

The LPA further interviewed five additional residents (R2-R6), all of whom stated that their needs are being met. They indicated that staff cannot force them to participate in activities they do not want to engage in because they have rights. Each resident expressed that they had a scheduled shower unless they chose to refuse it. The LPA was unable to interview R1, as R1 no longer resides at the facility and moved out on September 30, 2024. On December 11, the LPA also reviewed R1’s physician report (LIC602A), which showed that R1 was capable of dressing, grooming, and feeding themselves.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20240530120048
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: 12/16/2025
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur; therefore, the allegation is Unsubstantiated.

Allegation #2: Staff did not assist a resident with arranging medical care.

The complaint alleged that the resident presented with a left eye mass, causing pain and vision loss. R1 reported experiencing pain for a week, but the facility only sent R1 to the hospital. On December 11, 2025, the LPA interviewed the Administrator (A1), who denied the allegation and stated that the facility had made several appointments for R1 to see R1's primary doctor, but R1's responsible party kept cancelling the doctor appointments. On the same day, the LPA interviewed five staff members, #1-5 (S1-S5), who also denied the allegation. S1 also stated that S1 made several appointments for R1, but R1, the responsible party, cancelled the appointments. Finally, S1 decided to call 911 and sent R1 to the hospital. S1 also stated that the facility tried to have the facility doctor see R1, but R1 refused. The LPA also interviewed five residents #2-6 (R2-R6), all of whom denied the allegation and stated that they had seen the facility doctor twice a month. If they need more urgent care, the facility will call 911. LPA was unable to interview R1 because R1 no longer resides at the facility and moved out on September 30, 2024.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur; therefore, the allegation is Unsubstantiated.

No deficiencies cited. An exit interview was conducted. A copy of the report was provided to the Administrator Maria Forkrud.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3