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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426330
Report Date: 05/19/2025
Date Signed: 05/19/2025 03:14:12 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
12/05/2024 and conducted by Evaluator Yolanda Delgado
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20241205161237
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: 75DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Maria Forkrud, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff does not ensure that residents are provided a safe environment.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation pertaining to the allegation listed above. LPA met with Maria Forkrud and explained the purpose of the visit.

On December 5, 2024, Community Care Licensing received a complaint alleging Staff does not ensure that residents are provided a safe environment. LPA conducted interviews with Administrator, staff, residents, and additional witnesses. LPA also conducted a review of pertinent documentation. Regarding the allegation staff does not ensure that residents are provided a safe environment, it was reported that residents being kept in rooms during construction to walls with exposure to extreme mold and debris. Information obtained from the interview with Administrator denied that any construction has taken place at the facility were construction to walls with exposure to extreme mold and debris.

(Continued on Page 2)
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
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-20241205161237
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/19/2025
NARRATIVE
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(Continued from Page 1)

Information obtained from interviews with Residents could not corroborate the allegation that they were kept in rooms during construction to walls with exposure to extreme mold and debris. Information obtained from an interview with a witness stated that there was a plumbing issue at 175 N Girard Ave, Independent Living Building, not at 155 N Girard Ave, Assisted Living.

Based on staff interviews, resident interviews, witnesses’ interviews, facility records. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with Maria Forkrud and a copy of this report along with LIC811- Confidential Names list was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2