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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426330
Report Date: 05/25/2022
Date Signed: 05/25/2022 05:09:09 PM


Document Has Been Signed on 05/25/2022 05:09 PM - It Cannot Be Edited

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:RAQUEL MONTESFACILITY TYPE:
740
ADDRESS:155 N. GIRARD ST.TELEPHONE:
(951) 658-2274
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:120CENSUS: 64DATE:
05/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Care Director- Maria NavaresTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and met with administrator, Raquel Montes, who was informed of the purpose of the visit. At the time of visit there was 20 staff and 64 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA advised adminsitrator to repost Covid-19 postings at the facility. A single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA observed a sufficient 30-day supply of PPE equipment. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces.

LPA reviewed facility roster on Guardian and compared this to Employee Roster provided by the administrator. LPA reviewed transfer sheets on file for staff and found 4 staff (S1, S2, S3 and S4) not associated to the facility. S4 was brought to the facility on a temporary basis from 04/03/2022 to 05/19/2022 from facility Vista Del Mar.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/25/2022
NARRATIVE
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LPA was able to review documented proof of this at the facility. S1, S2 and S3 are not associated to the facility. This is a zero tolerance regulation and a Type A citation will be assesed with civil penalties in the amount of $500 per staff, totaling $1500.

An exit interview was conducted, and a copy of this report, 809-D pages, and appeal rights were provided to facility administrator Raquel Montes.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/25/2022 05:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
80019(e)(2)
"Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 80019(f)…"

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with S1 not being associated to the facility. This is a zero tolerance regulation and poses an immediate health, safety or personal rights risk to persons in care. A civil penalty will be assessed in the amount of $500.
POC Due Date: 05/26/2022
Plan of Correction
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Administrator will submit updated LIC500 for S1 to the department by POC date.
Request Denied
Type A
Section Cited
CCR
80019(e)(2)
"Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f)…"


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with S2 who was not associated to the facility. This is a zero tolerance regualtion and poses an immediate health, safety or personal rights risk to persons in care. Civil oenalties will be assesed in the amount of $500.
POC Due Date: 05/26/2022
Plan of Correction
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Administrator will submit updated LIC500 for S2 to the deparmtent by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/25/2022 05:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
80019(e)(2)
"Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 80019(f)…"


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above with S3 not being associated to the facility. This is a zero tolerance regulation and poses an immediate health, safety or personal rights risk to persons in care. Civil Penalties with be assesed in the amount of $500 for this.
POC Due Date: 05/26/2022
Plan of Correction
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Administrator will send the department the transfer request for S3 by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4