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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426330
Report Date: 10/14/2020
Date Signed: 10/15/2020 09:43:22 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/07/2020 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201007151314
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: 62DATE:
10/14/2020
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Raquel MontesTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility is not in good repair.
Unlawful 3-day eviction.
Resident's prescribed medications have been misplaced.
Meals served do not meet the daily requirements.
Resident's prescribed medications have been misplaced.
Facility did not notify responsible party of resident having multiple falls.
Facility does not have properly functioning smoke detectors.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Williams contacted the facility to initiate a complaint investigation into the above allegations via telephone due to the COVID-19 pandemic. LPA identified herself and discussed the purpose of the call and the elements of the allegations with the Administrator, Raquel Montes.

LPA interviewed the Administrator and Staff #1 (S1) who both stated that Resident #1 (R1) resides in the Independent Living (IL) building, which is not licensed by Community Care Licensing (CCL), located at 175 N. Girard St. Hemet, CA 92544. According to the Administrator, R1 has resided in the IL building since, 4/04/2018 , and has never been a resident of the Assisted Living building, which is licensed by CCL. The Administrator provided LPA with a resident roster and admission agreement which indicated R1 was a resident of the IL building.

This agency has investigated the complaint of the above allegations. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020
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 18-AS-20201007151314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 336426330
VISIT DATE: 10/14/2020
NARRATIVE
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reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted via telephone and a copy of this report was provided via email to the administrator.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2