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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426330
Report Date: 09/06/2024
Date Signed: 09/06/2024 02:30:15 PM


Document Has Been Signed on 09/06/2024 02:30 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: 79DATE:
09/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Maria Forkrud, administratorTIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced case management visit in response to an incident report received by the department. LPA met with the administrator, Maria Forkrud, and she was informed of the purpose of the visit.

On 8/16/2024 the department received an incident report for Resident #1 (R1), incident had occurred on 8/14/2024. LPA conducted a walk through, interview and records review at the time of the visit.

No deficiencies were cited at the time of the visit. An exit interview was conducted with the administrator where this report was reviewed and provided to her.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo JeonTELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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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