336426330-5-21-2024-18-AS-TDAN-D5K2DZ-20240523171906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426330
Report Date: 11/10/2022
Date Signed: 05/21/2024 10:49:25 AM

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
11/07/2022 and conducted by Evaluator Crystal Colvin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20221107161436

FACILITY NAME:	VISTA MONTANA SENIOR LIVING		FACILITY NUMBER:	336426330
ADMINISTRATOR:	MARYANN KANEKOA		FACILITY TYPE:	740
ADDRESS:	155 N. GIRARD ST.		TELEPHONE:	(951) 658-2274
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	120	CENSUS: 65	DATE:	11/10/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Maria Nevarez - Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility failed to meet needs of resident

INVESTIGATION FINDINGS:

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Licensing Program Analsy (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initating and investigation for the above allegation(s). LPA Colvin met with Administrator Maria Nevarez and informed her of the prupose of today's inspection. Below is a summary of the findings:

Regarding allegation "Facility failed to meet needs of resident": LPA Colvin conducted interviews with facility staff and resident (R1), as well as reviewed facility records for R1 in relation to R1’s rash underneath their breast/upper abdomen. LPA Colvin learned through interviews with multiple staff members that in September and October of 2022, R1 was going through a depressive episode due to a recent breakup with another resident. During this time period, R1 was refusing to shower and refusing assistance with showering, which lead to exacerbation of an ongoing issue with a rash R1 had. LPA Colvin additionally learned that R1 was also consistently refusing treatment for the rash, though the facility staff failed to document this accurately on the Medication Administration Record (MARs) and LPA Colvin confirmed with Medication Technician and Resident Services Director that the refusals were in fact occurring.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20221107161436

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: 11/10/2022

NARRATIVE

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LPA Colvin observed in staff notes that R1 refused to go to the hospital on multiple occasions (unrelated to rash) and additionally refused to go to a psychiatric facility when it was recommended. Staff interviews relayed that there was a terrible odor coming from R1’s room due to R1 not showering, and staff additionally stated that R1 was sleeping and drinking excessively during this time, and even stayed in bed for a period of two weeks. LPA Colvin asked the Administrator if anything else was done in regards to R1’s decline in condition, such as having R1 evaluated for a psychiatric hold for danger to self or grave disability. Administrator relayed to LPA Colvin that this was not done, nor was R1 provided with an eviction notice or warning of eviction notice (despite R1 breaking facility rules) and that staff were encouraged to check in on R1 and try to convince R1 to shower/accept care. LPA Colvin learned from staff interviews that R1’s condition only improved due to R1’s own decision to get better after R1’s last admission to the hospital on 11/5/22 for a fall.

Due to information provided from interviews and record review, LPA Colvin observed that the facility failed to provide necessary assistance to R1, as facility staff did not have R1 evaluated for 51/50 psychiatric hold, or take other measures to attempt to convince R1 of allowing for care, such as providing R1 with eviction notice or warning of eviction notice. This method would have likely proven to be effective, as LPA Colvin learned through interviews that R1 is a “people pleaser” and views the facility as all they have left and does not want to be in trouble. Therefore, based on interviews conducted and review of facility records, the allegation “ Facility failed to meet needs of resident“ is SUBSTANTIATED.

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

Due to observations made by LPA Colvin, the facility was cited and deficiency noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy of all reports, forms, and appeal rights were provided to Administrator Maria Nevarez during the exit interview.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20221107161436

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: 11/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 11/11/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in ...Facilities: (a) In addition to the rights listed ...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff...to meet their needs. This requirement was not met by:	1 2 3 4 5 6 7	Licensee agrees to develop a plan of action for situations such as resident self-neglect and refusal of services for when residents are self-responsible. Licensee to consult with mental health professionals regarding options such as involuntary psychiatric holds or considering possible eviction notices. Licensee to provide
	8 9 10 11 12 13 14	Based on interview and record review, the Licensee did not comply with the above regulation with one resident. LPA Colvin observed that R1 went approx. 2 months in consistent denial of bathing and allowing care for rash. Staff did not seek additional means to get resident care. This was immedaite health risk to R1.	8 9 10 11 12 13 14	LPA Colvin with detailed plan, which staff shall be trained on (fLicensee to provide proof of training within 30 days) to LPA Colvin by Plan of Correction date of 11/11/22.
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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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022

LIC9099 (FAS) - (06/04)

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