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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426330
Report Date: 02/28/2022
Date Signed: 02/28/2022 12:51:18 PM

Substantiated


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
01/24/2022 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220124122518
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: 62DATE:
02/28/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Raquel Montes, Assistant AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff are not allowing hospice staff into facility to provide care to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to deliver findings on the above allegation. LPA met with Assistant Administrator Raquel Montes. LPA interviewed Resident One (R1), and after record review, and previous interview of Administrator who confirmed that the order was made to not allow R1s new hospice agency to provide services, LPA determined the above complaint was deemed to be SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted, and copies of this report, LIC811, LIC9099-D, and Appeal Rights were discussed with and provided to Ms. Montes.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022
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-20220124122518
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2022
Section Cited
CCR
87468.1(a)(16)
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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES: (a) Residents... facilities..personal rights: (16) To receive.. This requirement was not met as evidenced by:
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Administrator agrees to continue allowing Peaceful Heart Hospice to service R1. Upon record review, POC was cleared on date of visit.
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Based on LPAs review of records, and interviews, Licensee did not adhere to the regulation. This presents a potential health and safety and personal rights risk to residents in care.
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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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2