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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426330
Report Date: 05/18/2021
Date Signed: 05/18/2021 12:17:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VISTA MONTANA SENIOR LIVINGFACILITY NUMBER:
336426330
ADMINISTRATOR:MARILOU CARLSONFACILITY TYPE:
740
ADDRESS:155 N. GIRARD ST.TELEPHONE:
(951) 658-2274
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:120CENSUS: 58DATE:
05/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Raquel MontesTIME COMPLETED:
12:20 PM
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Licensing Program Analyst's (LPA's) Stephanie Williams and Elecia Weathersby made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Williams and Weathersby arrived and was asked to provide a temperature reading by a facility staff member. LPA's met with Administrator, Raquel Montes, who confirmed that there are currently no cases/exposures of COVID-19 within the facility.

During the inspection, LPA Williams and Weathersby conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. LPA's observed that the facility was taking proper measures to screen residents and visitors upon arrival. LPA's also observed appropriate postings throughout the facility, including self-monitoring/symptom assessment postings and hand-washing etiquette postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a 14+ day supply of Personal Protective Equipment (PPE). LPA Williams and Weathersby also observed that all staff members and visitors were properly fitted with face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining clients, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the client presents any COVID-19 symptoms.

LPA Williams and Weathersby observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview was conducted where this report was discussed and a copy of this report was also provided to Montes at the conclusion of the inspection.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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