336426330-5-30-2023-18-AS-JESL-CSE8PQ-20230601224155

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426330
Report Date: 05/30/2023
Date Signed: 05/30/2023 02:43:17 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/24/2023 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230524171521

FACILITY NAME:	VISTA MONTANA SENIOR LIVING		FACILITY NUMBER:	336426330
ADMINISTRATOR:	MARYANN KANEKOA		FACILITY TYPE:	740
ADDRESS:	155 N. GIRARD ST.		TELEPHONE:	(951) 658-2274
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	120	CENSUS: 72	DATE:	05/30/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Maryann Kanekoa, Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility is not providing a safe environment for residents in care.

INVESTIGATION FINDINGS:

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Licesning Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation for the allegation listed above. LPA met with Maryann Kanekoa, Administrator, where LPA explained the purpose of the visit and the elements of the allegation. The allegaton was investigated, the investigation consisted of observations, interviews and record review.

Regarding the allegation facility is not providing a safe environment for residents in care. It was reported that Resident #1(R1) is aggressive, demeaning and inappropriate to both residents and facility staff. Interview with the Administrator Maryann confirmed that there has been an ongoing issue with R1 and their behavior such as making threats to cause physical harm by stating that they would kill another individual, stab someone with a knife, as well as use racial slurs. LPA reviewed facility incident reports that note R1's offensive language, name calling and acts of physical aggression by hitting another individual with their power chair. During an interview with R1, LPA discussed the importance of feeling safe, respected and

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20230524171521

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 336426330
	VISIT DATE: 05/30/2023

NARRATIVE

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comfortable for everyone in the facility. R1 stated that they do make such statements, but stated that others make comments towards them as well. R1 stated that they understood and that things will be better moving forward. However, staff report that R1 always says that and when they are upset again, they do the same thing.

Additionally, Administrator Maryann informed LPA that R1 had to be taken off of their pain medication as they tested positive for methamphetamine at the beginning of May. The facility has contacted law enforcement because of threats that R1 has made. Staff was informed that nothing could be done until R1 acted on the threats that they have made. Based on interviews and record review the allegation of facility is not providing a safe environment for residents in care is SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated.

An exit interview was conducted and a copy of this report, 9099D, and appeal rights were provided to Maryann Kanekoa, Administrator .

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20230524171521

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 336426330
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/30/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/13/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.	1 2 3 4 5 6 7	The licensee agrees to conduct a house meeting for all residents where a review of personal rights, and facility expectation will be reviewed. Proof is to be submitted to the department by 5pm on the due date indicated.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: R1 has made threats to physcially harm others, demean others by calling derogatory names and using racial slurs. This poses a potential health, safety and personal rights risk in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC9099 (FAS) - (06/04)

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