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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426330
Report Date: 07/31/2024
Date Signed: 07/31/2024 01:01:35 PM


Document Has Been Signed on 07/31/2024 01:01 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: 78DATE:
07/31/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Interim-Administrator, Raquel MontesTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility for a case management visit to follow up on the elopement of a resident in care. The LPA was allowed entrance into the facility and met with Interim-Administrator, Raquel Montes. The LPA informed Montes of the purpose for the visit.

A report was received by the Department from the facility on 06/19/2024 regarding Resident One (R1) not being able to be located at the facility on 06/11/2024. Staff One (S1) attempted to locate R1 during their scheduled round; however, the resident was not found. According to the Unusual Incident/Injury Report (UIR) and a staff interview, R1 was last seen at 10:00 AM on 06/11/2024. The report states staff searched for the resident; however, their attempts were unsuccessful. Per Interim-Administrator Montes, R1 has not been found as of this date. R1's medical assessment (Physician's Report for Residential Care Facilities for the Elderly) was reviewed. The report, dated 12/14/2023, revealed the resident is diagnosed with a condition which does affect their cognition; however, the report also states the resident is able to leave the facility unassisted. According to staff interviews, R1 frequently leaves the facility without supervision and has returned on their own or with an escort from law enforcement. Montes reported that when R1 returns to the facility they have never returned injured.

The UIR (written report), regarding the elopement of R1 was not submitted within seven (7) days. Based on a fax transmittal the incident, which occurred on 06/11/24, was reported on 06/19/2024. A citation will be issued.

An exit interview was conducted; this report was reviewed with Interim-Administrator and a copy was provided, along with the LIC 811, LIC 9098, and instructions on appeal rights.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
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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Document Has Been Signed on 07/31/2024 01:01 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2024
Section Cited
CCR
87211(a)(1)

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REPORTING REQUIREMENTS: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to...: (1) A written report shall be submitted to the licensing agency... within 7 days of the occurrence of any of the events specified in (A) through (D)...
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The Interim-Administrator reported staff training regarding reporting requirements will be conducted and proof submitted to the Department.
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This requirement was not met, as evidenced by: Based on record review the licensee did not ensure a written report was submitted within 7 days regarding R1's elopment from the facility. This poses a potential threat to the health, safety and personal rights of the resident 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: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
LIC809 (FAS) - (06/04)
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