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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426330
Report Date: 10/25/2022
Date Signed: 10/25/2022 03:23:27 PM


Document Has Been Signed on 10/25/2022 03:23 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
CCLD Regional Office, 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: 66DATE:
10/25/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Administrator, Maria NevarezTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to conduct a health and safety visit. LPA met with administrator, Maria Nevarez who was informed of the purpose of the visit.

LPA conducted a tour of the interior and exterior of the facility. LPA observed the resident activity rooms, dining room, kitchen, resident rooms and bathrooms. LPA observed where the facility is keeping the resident medications locked in the med room locked in medication carts. LPA observed at least a 30-day supply of medications for residents. The facility has stores of the PPE equipment and cleaning supplies in room 100. LPA observed the laundry room which is kept locked and contains (3) working washers, and (3) working dryers. LPA observed the facility kitchen which possessed the appropriate 2-day supply of perishable and 7-day supply of non-perishable foods.

LPA requested a copy of the LIC500 Personnel Report and the Register of Residents. LPA checked staff listed for background check clearances and found that all staff listed where cleared.

No health and safety issues were noted during the time of the visit. No deficiencies were issued at the time of the visit.

An exit interview was conducted where a copy of this report was reviewed and provided to the administrator, Maria Nevarez.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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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