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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426330
Report Date: 08/29/2025
Date Signed: 08/29/2025 10:35:17 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
04/04/2022 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220404101121
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: 88DATE:
08/29/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Maria Forkrud, AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Residents are not accorded privacy while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver amended findings of the above allegation. LPA met with Maria Forkrud, Administrator. The Department investigation involved interviews with staff and review of records.

On April 4, 2022, Community Care Licensing Division (CCLD) received a complaint report alleging that residents are not accorded privacy while in care. Information received indicated two (2) different staff members entered a resident’s room without knocking or receiving permission to enter. Additionally, during interviews conducted by LPA, three (3) out of eight (8) residents stated some staff members had entered their rooms without knocking beforehand. All eight (8) residents stated all staff members now knock on the doors before entering their rooms.

Continuned on LIC9099-C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
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 3
Control Number 18-AS-20220404101121
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VISTA MONTANA SENIOR LIVING
FACILITY NUMBER: 336426330
VISIT DATE: 08/29/2025
NARRATIVE
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Based on the interviews and information received, the allegation that residents are not accorded privacy while in care is 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 copy of this report was provided to the Administrator along with LIC9099-D and Appeal Rights.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20220404101121
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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: 08/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2025
Section Cited
CCR
87468.2(a)(1)
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Additional Personal Rights of Residents in Privately Operated Facilities (a)In addition to the rights listed in Section 87468.1....(1)To have a reasonable level of personal privacy in accommodations.... This requirement was not being met as evidenced by:
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This deficiency has already been corrected as all staff now knock on the residents' doors and ask for permission to enter.
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Based on observations and interviews, LPA found that residents were not accorded privacy while 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.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3