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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426330
Report Date: 12/08/2021
Date Signed: 12/08/2021 11:37:33 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
336426330
ADMINISTRATOR:RAQUEL MONTESFACILITY TYPE:
740
ADDRESS:155 N. GIRARD ST.TELEPHONE:
(951) 658-2274
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:120CENSUS: 63DATE:
12/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marcella CalvilloTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced case management visit to address an SIR that came into the office for an incident that happened on 11/23/21 regarding Resident #1 (R1). LPA met with Administrator Marcella Calvillo and explained the purpose of the visit. LPA had spoken with Assistant Administrator Raquel Montes during the week of 11/29/21 to discuss the incident.

At the time of the visit, through record review of the resident involved, it was determined that the resident was able to leave the facility unassisted, thus no violations were observed.

Facility followed protocol and the investigation is complete.

No deficiencies observed at this time.

An exit interview was conducted with Administrator Marcella Calvillo and a copy of this report along with LIC 811 was provided.

SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 248-0341
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
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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