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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426330
Report Date: 09/29/2021
Date Signed: 09/29/2021 12:05:07 PM



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
08/19/2020 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200819171538
FACILITY NAME:VISTA MONTANA SENIOR LIVINGFACILITY NUMBER:
336426330
ADMINISTRATOR:MARILOU CARLSONFACILITY TYPE:
740
ADDRESS:155 N. GIRARD ST.TELEPHONE:
(951) 658-2274
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:120CENSUS: 65DATE:
09/29/2021
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Raquel MontesTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
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9
Staff kicked resident resulting in injuries
Staff did not give resident a shower for a long period of time.
INVESTIGATION FINDINGS:
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2
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9
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13
Licensing Program Analyst (LPA) Stephanie Williams conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA Williams identified herself and met with Administrator, Raquel Montes. The investigation consisted of records review and interviews with staff and residents.

In regards to allegation #1, LPA interviewed Staff #1 (S1) who denied that staff members physically abused Resident #1 (R1). S1 stated that R1's whereabouts are unknown. LPA also interviewed Staff #2 (S2) and Staff #3 (S3), who denied causing physical abuse towards R1 nor did either staff member eyewitness such incidence by other staff members. S1 and S2 stated that R1 had a history of threatening and aggressive behaviors towards staff. LPA Williams was unable to locate R1 to retrieve statement. LPA Williams attempted to contact R1's family members in an effort to locate R1; however, LPA Williams was unsuccessful. LPA interviewed Resident #2 (R2) and Resident #3 (R3), who all denied being and/or witnessing physical abuse caused by facility staff.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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-20200819171538
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: 09/29/2021
NARRATIVE
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In regards to allegation #2, LPA interviewed S1 who stated that the facility has a dedicated staff member who solely provides showering for residents. S1 stated that R1 was receiving showers three times a week.
LPA interviewed R2 and R3 who stated that the facility has been providing showers for them three times a week. LPA interviewed S2, S3, and S4 who stated that facility staff are providing each resident with a shower three times a week. LPA could not locate R1 in order to retrieve statement.

Based on evidence obtained during the investigation, LPA has determined that the above allegations are UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed and a copy was provided to the Administrator via email.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2