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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045920055
Report Date: 01/29/2026
Date Signed: 01/29/2026 11:31:30 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/08/2025 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20251208131336
FACILITY NAME:MONTE VISTAFACILITY NUMBER:
045920055
ADMINISTRATOR:WEBSTER, SIMONIEFACILITY TYPE:
735
ADDRESS:1262 14TH STREETTELEPHONE:
(916) 624-7800
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY:12CENSUS: 12DATE:
01/29/2026
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Christa Carrasco - administratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility did not seek timely medical attention for a client in care. - SUBSTANTIATED
INVESTIGATION FINDINGS:
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01/29/2026 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Christa Carrasco. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation LPA toured the facility, conducted interviews and reviewed documents.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
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 7
Control Number 59-AS-20251208131336
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MONTE VISTA
FACILITY NUMBER: 045920055
VISIT DATE: 01/29/2026
NARRATIVE
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Facility did not seek timely medical attention for a client in care.- SUBSTANTIATED

It was reported that a client is bulimic and has not been treated by a physician for their condition.

LPA reviewed LIC602 Physician’s Report dated 02/26/2025 for Client 1 (C1). The document does not include a diagnosis of bulimia for C1. LPA reviewed documentation of medical appointments on 12/12/2025 (labs), 12/19/2025 with an upcoming appointment for 01/29/2026. On 01/15/2026 R1 had a visit to the ER for symptoms unrelated to bulimia.

LPA reviewed care notes for C1 for July 2025. On four separate days it was reported that C1 was having issues with binge eating out of their personal snack supply and then throwing up in their room and the common area of the facility. It was also reported that C1 was refusing the meals provided by the facility.

All staff who were interviewed stated that C1 does not have a bulimia diagnosis but does struggle with eating.

Administrator stated the client had an issue with throwing up when they first moved in but the client saw a doctor then and it hasn’t been a problem since.

It was determined that although C1 does not have a bulimia diagnosis they do have an issue with not eating the meals provided by the facility and prefers to eat the snacks that they purchase for themselves. There are documented occurrences where C1 has vomited after these incidents of eating their snacks as opposed to the facility meals. The facility did not provide documentation that proves that C1 was seen by a physician after these reported incidents that occurred in July 2025. The allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Christa Carrasco.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20251208131336
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MONTE VISTA
FACILITY NUMBER: 045920055
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/12/2026
Section Cited
CCR
80075(a)
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80075(a) Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement was not met as evidenced by:
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The licensee agrees to schedule a medical appointment for C1 to be examined and treated and will submit proof of C1 attending this appointment to LPA.
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Based on interviews and records review the facility failed to arrange for 1 of 12 clients to be seen by their medical provider when they refused to eat healthy meals and ate unhealthy food which resulted in the client vomiting several times in their room and in the common area of the facility. This poses a potential health, safety and personal rights risk to clients in care.
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The licensee shall send LPA the date of the scheduled appointment by 02/12/2026. Once C1 has completed the appointment the licensee shall send LPA documented proof from C1's physician which confirms the appointment was completed.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/08/2025 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20251208131336

FACILITY NAME:MONTE VISTAFACILITY NUMBER:
045920055
ADMINISTRATOR:WEBSTER, SIMONIEFACILITY TYPE:
735
ADDRESS:1262 14TH STREETTELEPHONE:
(916) 624-7800
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY:12CENSUS: DATE:
01/29/2026
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Christa Carrasco - administratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility has bed bugs, roaches and black widow spiders. - UNSUBSTANTIATED
Washer, dryer and dish washer are broken. - UNSUBSTANTIATED
Clients are not provided dignity in their relationships with staff. - UNSUBSTANTIATED
Facility withheld food from a client in care. - UNSUBSTANTIATED
Medication left accessible to clients in care. – UNSUBSTANTIATED
INVESTIGATION FINDINGS:
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01/29/2026 10:45 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Christa Carrasco. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation LPA toured the facility, conducted interviews and reviewed documents.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 59-AS-20251208131336
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MONTE VISTA
FACILITY NUMBER: 045920055
VISIT DATE: 01/29/2026
NARRATIVE
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Facility has bed bugs, roaches and black widow spiders.- UNSUBSTANTIATED

It was reported that the facility has bed bugs in every single room and there are roaches and black widows all over the facility.

During a tour of the facility on 12/18/2025 LPA checked the bedding on four client beds and did not observe any bed bugs or droppings. LPA did not observe any roaches or black widow spiders inside of the facility on the day of the inspection.

LPA reviewed pest control invoices for the past three months that show the facility is being professionally serviced monthly for pests.

LPA interviewed six clients regarding bed bugs. All clients reported they had never seen any bed bugs and had not been bitten while living in the home.

During staff interviews it was learned that pest control provides monthly service and staff deep clean on Mondays and Saturdays.

Administrator stated the facility does not have bed bugs, pest control services the facility monthly and if staff see anything that needs to be addressed they call pest control to make sure there are no pests.

This allegation is unsubstantiated.

Washer, dryer and dish washer are broken. - UNSUBSTANTIATED

It was reported that the washer, dryer and dishwasher are broken.

During a tour of the facility on 12/18/2025 LPA turned dryer on and observed no issues with its function. LPA observed washing machine in use, no issues. LPA observed dishwasher in use, no issues.

Staff interviews confirmed that the washer, dryer, and dishwasher are all functioning.

Administrator stated the dryer and dishwasher are not broken

This allegation is unsubstantiated.

Continued on LIC9099-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 59-AS-20251208131336
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MONTE VISTA
FACILITY NUMBER: 045920055
VISIT DATE: 01/29/2026
NARRATIVE
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Clients are not provided dignity in their relationships with staff.- UNSUBSTANTIATED

It was reported that staff talk down to the clients and mention things about clients’ medical issues on social media.

LPA reviewed screen shots of a social media post that was submitted. An individual who is not on the staff list for the facility made comments on the post referring to client’s mental health and transition status but did not specifically name any client, facility, or status details.

During interviews staff stated they had not talked down to or have not witnessed other staff talking down to clients.

Administrator stated that the social media allegation was reported and the company investigated and unfounded because the Facebook page in question does not belong to the accused staff but to a totally random person.

This allegation is unsubstantiated.

Facility withheld food from a client in care. - UNSUBSTANTIATED

It was reported that a client wouldn’t eat the meals that were prepared and staff wouldn’t give the client the food they bought for themselves which is locked in a cupboard.

During a tour of the facility on 12/18/2025 LPA observed that each client has their own labeled and locked cabinet where they store snacks. Clients are aware that all they have to do is ask staff to unlock the cabinet if they would like access to their snacks.

LPA reviewed care notes for C1 for July 2025. On three separate days it was reported that C1 was having issues with binge eating out of their personal snack supply and then throwing up in their room and the common area of the facility. It was also reported that C1 was refusing the meals provided by the facility.

Staff interviews revealed that C1 often refuses the facility meals and prefers to eat their own snacks and snacks that are provided by the facility. Staff stated that C1 can access their own snacks at any time or can ask staff for a facility snack at any time.

Administrator stated the client buys snacks and has a cabinet that stores the food which the client eats from regularly.

It was determined that C1 has access to their snacks, facility snacks, and is offered three meals a day by the facility. This allegation is unsubstantiated.

Continued on LIC9099-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 59-AS-20251208131336
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MONTE VISTA
FACILITY NUMBER: 045920055
VISIT DATE: 01/29/2026
NARRATIVE
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Medication left accessible to clients in care.- UNSUBSTANTIATED

It was reported that there were a few incidents where staff left medication accessible and another client had taken the medications.

During a tour of the facility on 12/11/2025 LPA observed that all medication is stored in a locking cabinet in a locked office.

LPA reviewed an incident report that was submitted to licensing in 2024 concerning this medication error. The facility conducted medication training with staff to prevent future incidents.

Staff interviews revealed that this incident did occur but staff were provided with medication training and there have been no further incidents.

Administrator stated there was one incident that occurred a long time ago which was reported to licensing.

It was determined that the incident occurred last year, the facility reported the incident to licensing and conducted staff training to prevent it from occurring again. There have been no other occurrences. The allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.

No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Christa Carrasco.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7