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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426330
Report Date: 05/30/2024
Date Signed: 05/30/2024 06:17:56 PM


Document Has Been Signed on 05/30/2024 06:17 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:VISTA MONTANA SENIOR LIVINGFACILITY NUMBER:
336426330
ADMINISTRATOR:MARYANN KANEKOAFACILITY TYPE:
740
ADDRESS:155 N. GIRARD ST.TELEPHONE:
(951) 658-2274
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:120CENSUS: 76DATE:
05/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Maryann Kanekoa Nevarez, AdministratorTIME COMPLETED:
06:20 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility for a required annual inspection. The LPA was allowed entrance into the facility and met with Administrator, Maryann Kanekoa Nevarez. The LPA informed the Administrator of the purpose for the visit. The inspection included the following:

Physical Plant: The facility has an approved fire clearance for 120 non-ambulatory residents, of which 10 may be bedridden. The LPA inspected the facility; there are no bodies of water located on the property. According to Administrator Nevarez, no weapons are stored in the facility. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats or strips present. The alarm panel for the smoke and carbon monoxide detectors was observed to be in a normal status. The facility was kept clean.

Food Service: There is a minimum of two (2) days supply of perishable foods and one (1) week's supply of non-perishable foods available. Sufficient supplies were available for resident's dinning use.

Record Review: The facility currently has an approved Hospice Waiver for twenty (20) residents; of which eleven (11) are currently receiving services. Staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Complete training on Dementia Care, Postural Supports, Restricted Health Conditions, and Hospice Care was not observed to be on file for staff. Two staff members, S3 and S5, did not have proof of Dementia Care training. S2, S3, and S4 did not have Restricted Healthcare training. S2, S3, S4, and S5 did not have postural support training or the complete hours for hospice care training. A citation will be issued. Initial medication training was not observed on file for S5. A citation will be issued. Training was observed on file relating resident's rights. There is a disaster and mass casualty plan in place. Emergency Drills are being completed. Services requiring specialized skill are
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/30/2024
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being performed by appropriately skilled professional. The Appraisal/Needs and Services Plan for R2, R3 and R5 were not updated within a 12 month period. Physician's Report for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) and Admission Agreements were observed on file. No written agreement was observed on file for residents receiving services from home health agencies; including for R6, R7 and R8. A citation will be issued. The LPA was informed there were residents in care with Restricted Health Conditions who are not receiving services from a hospice or home health agency. According to Administrator Nevarez, there were no exception requests submitted to the department to retain the residents. A citation will be issued.

Medication Review: The LPA inspected the medication room and carts. The medications were observed to be well organized and inaccessible to unauthorized individuals. Centrally Stored Medication and Destruction records were observed to be maintained at the facility.

An exit interview was conducted with Administrator Nevarez, in which this report was reviewed and a copy was provided, in addition to the LIC 811. Due to technical concerns a return visit will need to be completed to issue citations.

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC809 (FAS) - (06/04)
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