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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 12:17:34 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
09/24/2024 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 18-AS-20240924112333
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:
11:06 AM
MET WITH:Maria ForkrudTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Facility failed to notify resident's family about their death in a timely manner.
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 allegation. 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 April 22, 2025, Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with the administrator, Maria Forkrud, and informed her 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 04/23/24) for Residents #1 (R1), and R1's face sheet. Physician Report (dated 04/22/24), for R1. Physician Orders for Life-Sustaining Treatment (POLST dated 11/16/2023). Unusual Incident Report missing R1, and R1 Death Report (dated September 24, 2024). LPA also conducted interviews with five Residents (R2-R6), five Staff members (S1-S5), one Med Tech (MT), 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-20240924112333
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: Facility failed to notify the resident’s facility about their death in a timely manner.

The complaint alleged that the resident left the facility on September 22, 2024, and was struck by a car while crossing the street. Resident #1 (R1) passed away on September 23, 2024, at approximately 7:30 PM. However, the facility did not notify the family until September 24, 2024.

On December 11, 2025, LPA Richard interviewed the administrator (A1), who stated that Med Tech had informed the Resident Care Director (RCD) about a call from the coroner confirming R1's passing. The administrator also mentioned that the facility had filed a missing person report with the Hemet Police Department and was actively searching for the residents.

At approximately 10:00 PM on September 23, 2024, the coroner's office contacted the facility to inform them of R1's passing. The coroner instructed them not to notify the family at that time, as they would handle the notification themselves. On December 16, 2025, LPA Richard interviewed one Med Tech (MT) by phone, who corroborated receiving a call from the coroner. The coroner's instruction not to inform the family was the reason they were not notified of R1's passing sooner.

Report Continued on LIC9099C.

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-20240924112333
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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 On December 11, LPA Richard reviewed the facility's Unusual Incident Report dated September 24, 2024, and the Death Report dated the same day. These reports indicated that the facility submitted an unusual incident report to the Community Care Licensing Department regarding R1's status as missing and their subsequent passing. LPA Richard was unable to interview R1 due to their passing on September 23, 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 were 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