336426330-5-16-2025-18-AS-APEZ-DGQSWE-20250516141413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426330
Report Date: 05/16/2025
Date Signed: 05/16/2025 02:14:28 PM

Document Has Been Signed on 05/16/2025 02:14 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 LIVING		FACILITY NUMBER:	336426330
ADMINISTRATOR/ DIRECTOR:	MARIA FORKRUD		FACILITY TYPE:	740
ADDRESS:	155 N. GIRARD ST.		TELEPHONE:	(951) 658-2274
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY: 120	TOTAL ENROLLED CHILDREN: 0	CENSUS: 76	DATE:	05/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Executive Director Maria Forkrud		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

NARRATIVE

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Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Executive Director Maria Forkrud. The LPA informed the Administrator of the purpose for the visit. The inspection included the following:

LPA toured Building C, which is designated as the assisted living section, inside and outside. LPA observed the facility to be clean and in good repair. The building is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured within regulation in 8 randomly selected rooms. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats present. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals on the first floor. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility and no bodies of water observed.

LPA began review of client records. Ten (10) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available and complete.

LPA reviewed employee records- Ten (10) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 11/04/2025.

Jazmond D Harris	TELEPHONE: (951) 529-2439
Armando Perez	TELEPHONE: (951) 248-2222
	DATE: 05/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 05/16/2025

NARRATIVE

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LPA observed four out ten records did not have the health screening/ TB test results completed and four out of ten did not have the First Aid/CPR certification completed. A deficiency will be issued for each violation.

LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present.

Medications are centrally stored. There is a locked room in the first floor allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers was last serviced on 11/26/2024, Fire drills are conducted monthly at the facility with the last drill on 04/01/2025 .

Based on the information received during this visit today in the areas reviewed, there are deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations.

This LIC 809, LIC 809-C, 809-D and Appeal Rights report was reviewed with the facility representative and a copy was provided.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 529-2439
LICENSING EVALUATOR NAME: Armando Perez	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/16/2025 02:14 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: 05/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above in four out of ten personnel files which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/06/2025
	Plan of Correction
1 2 3 4	Executive Director will be notifying the required staff and submit to LPA proof by email the First Aid certification by POC date.

Type B

Section Cited

CCR

87412(a)(11)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in four out of ten personnel records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/06/2025
	Plan of Correction
1 2 3 4	Executive Director will notify the required staff and will email LPA proof of the health Screening and TB test results by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Jazmond D Harris	TELEPHONE: (951) 529-2439
Armando Perez	TELEPHONE: (951) 248-2222
	DATE: 05/16/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

LIC809 (FAS) - (06/04)

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