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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604144
Report Date: 02/12/2026
Date Signed: 02/12/2026 12:38:27 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
10/17/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 18-AS-20231017113318
FACILITY NAME:MONTE VISTA MANORFACILITY NUMBER:
374604144
ADMINISTRATOR:ILICH, VESNAFACILITY TYPE:
740
ADDRESS:2331 MONTE VISTA DRTELEPHONE:
(760) 536-3114
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 5DATE:
02/12/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:ILICH VESNATIME COMPLETED:
12:38 PM
ALLEGATION(S):
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Staff handled resident in a rough manner.
Staff do not treat residents with dignity and respect.
INVESTIGATION FINDINGS:
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On 02/12/2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced follow-up complaint visit. LPA met with staff member Jaqueline, and the purpose of the visit was explained. The Administrator Vesna Ilich later joined the LPA.
The investigation consisted of the following: On 10/26/2023, Licensing Program Analyst (LPA) Venus Mixson conducted an initial unannounced investigation visit. LPA Mixson met with Administrator Vesna Ilich. On 02/12/2026, the Department interviewed the Administrator (A1), two staff members #1-2 (S1-S2), three residents #1-3 (R1-R3), and one witness #1 (W1). The department reviewed several documents, including the Staff Roster (dated 01/21/26), Resident roster (dated 1/14/26) (R1’s), Physician Report (dated 03/13/24), Admission Agreement, Unusual Incident Report (Dated 03/05/2024), and other pertinent records associated with this complaint.

(Evaluation Report continues LIC 9099--C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
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 4
Control Number 18-AS-20231017113318
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: MONTE VISTA MANOR
FACILITY NUMBER: 374604144
VISIT DATE: 02/12/2026
NARRATIVE
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Allegation #1: Staff roughly handled a resident.

The complaint alleged that a staff member was rough and impatient while preparing a resident for the morning, pulling on R1's arm and shoulder.

On 02/12/2026, between 10:38 am and 11:30 am, the Department interviewed the Administrator (A1) about the allegation. A1 denied the allegation and said that staff are trained to use appropriate techniques to assist residents based on their abilities. A1 mentioned that staff are instructed to contact A1 if a resident appears uncomfortable or in pain and to file a report if a resident reports an injury. A1 stated they were not aware of any caregiver handling a resident roughly to prepare the resident for the morning.

On 02/12/2026, between 10:43 am and 11:30 am, the Department interviewed 2 staff members #1-2 (S1-S2) regarding the allegation. Both staff members denied the allegation and stated that they did not handle the residents roughly.

On 02/12/2026, between 10:43 am and 11:30 am, the LPA interviewed three residents (R1-R3) regarding the allegation. All three residents denied the allegation and stated that they had never been handled roughly by staff. R1 also mentioned that the staff is very helpful. On 02/12/26, at 11:00 am, the department interviewed a witness (W1), who also denied the allegation that R1 was roughly handled by staff.

Report continued on LIC9099C

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

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20231017113318
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: MONTE VISTA MANOR
FACILITY NUMBER: 374604144
VISIT DATE: 02/12/2026
NARRATIVE
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On 02/12/2026, between 10:30 am and 11:30 am, the Department conducted a records review and found no incident reports or resident notes related to this allegation.

Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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 do not treat residents with dignity and respect.

The complaint alleged that a staff member berated R1 by saying, " Come on, you can get up,” and by pulling R1's paralyzed arm.

On 02/12/2026, between 10:30 am and 11:30 am, the Department interviewed the Administrator (A1) about the allegation. A1 denied the allegation and stated that staff are trained to treat all residents with respect. A1 also said that if a staff member mistreats a resident, A1 would retrain the staff member on the resident's rights. Additionally, no residents have ever complained to A1 about not being treated with respect and dignity.

On 02/12/2026, between 10:30 am and 11:30 am, the department interviewed two staff members (S1-S2) regarding the allegation. 2 out of the 2 staff members denied the allegation and stated that they treat residents with dignity and respect because the facility is their home.

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

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20231017113318
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: MONTE VISTA MANOR
FACILITY NUMBER: 374604144
VISIT DATE: 02/12/2026
NARRATIVE
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On 02/12/2026, between 10:30 am and 11:30 pm, the Department interviewed three residents (R1-R3) about the allegation. All three residents denied the allegation and said they had never been disrespect or treated without dignity. R1 specifically stated there was no pulling or pushing. On 02/12/2026, the Department also interviewed one witness (W1), who denied the allegation and stated that W1 had never seen staff disrespect R1.

On 02/12/2026, between 10:30 am and 11:30 am, the Department conducted a records review and found no incident reports or resident notes regarding this allegation.

Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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. Therefore, the allegation is UNSUBSTANTIATED.

No deficiencies were cited.

An exit interview was conducted, and a copy of this report was provided to Administrator Vesna Ilich.

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

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4