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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601496
Report Date: 01/30/2023
Date Signed: 01/30/2023 04:34:27 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/26/2023 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230126163852
FACILITY NAME:MONTANA VISTAFACILITY NUMBER:
198601496
ADMINISTRATOR:CAROLYN WESTFACILITY TYPE:
735
ADDRESS:355 WEST MONTANA STREETTELEPHONE:
(626) 398-8519
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:6CENSUS: 4DATE:
01/30/2023
UNANNOUNCEDTIME BEGAN:
01:54 PM
MET WITH:Jana West, SupervisorTIME COMPLETED:
04:44 PM
ALLEGATION(S):
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Facility staff hit resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Staff / Patricia Dahl and was later joined by the Supervisor Jana West who assisted with the visit. LPA explained the purpose of today’s visit is to discuss the above mentioned allegation of Facility staff hit resident while in care.

During today's visit, LPA interviewed Staff #1- #6 (S1-S6) Client #1-#5 (C1-C5) and residents clients #1- -#5. C1-C5. LPA reviewed the file of Client #5 and copies of the following documents in reference to Client #5; -Face Sheet, -Unusual Incident/Injury Report (date of incident: 09/06/2022, 09/26/2022 10/06/2022, 10/07/2022 12/01/2022, 12/02/0222,12/19/2022, 01/16/2023, 01/25/2023, -Individual Program Plan from Frank D. Lanterman Regional Center dated: 05/19/2021, Arroyo Day program incident reports dated 12/01/2022, 01/12/2023, and 1/18/2023.

(Continued on 809C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
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 2
Control Number 28-AS-20230126163852
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MONTANA VISTA
FACILITY NUMBER: 198601496
VISIT DATE: 01/30/2023
NARRATIVE
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Regarding Allegation: Facility staff hit resident while in care. It is alleged that a staff hit client on 01/25/2023. LPA interviewed 6 staff and 6/6 staff denied the allegation. LPA interviewed all 5 residents and 4/5 residents denied the allegation. One residents collaborated the allegation but was unable to identify the staff member. Witness #1 (W1) stated W1 did not witness the incident and unable to identify staff who allegedly hit client. W2 stated W2 did not witness the alleged incident.

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.

An exit interview was conducted and a copy of this report was provided to the Supervisor Jana West
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2