374604144-2-12-2026-18-AS-RORN-DRSRVK-20260302122140

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604144
Report Date: 02/12/2026
Date Signed: 02/12/2026 02:12:05 PM

Unsubstantiated

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
03/03/2023 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 18-AS-20230303101603

FACILITY NAME:	MONTE VISTA MANOR		FACILITY NUMBER:	374604144
ADMINISTRATOR:	ILICH, VESNA		FACILITY TYPE:	740
ADDRESS:	2331 MONTE VISTA DR		TELEPHONE:	(760) 536-3114
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	6	CENSUS: 5	DATE:	02/12/2026
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	ILICH VESNA		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff do not let residents come out of their rooms.
Staff yell at residents in care.
Staff do not provide proper toileting assistance to residents in care.

INVESTIGATION FINDINGS:

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On 02/12/2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced follow-up complaint visit. LPA met with staff member Jaqueline, and the purpose of the visit was explained. The Administrator Vesna Ilich later joined the LPA.
The investigation consisted of the following: On 03/08/2023, Licensing Program Analyst (LPA) Venus Mixson conducted an initial, unannounced investigation visit. LPA Mixson met with Administrator Vesna Ilich. On 02/12/2026, the Department interviewed the Administrator (A1), two staff members #1-2 (S1-S2), three residents #1-3 (R1-R3), and one witness #1 (W1). The department reviewed several documents, including the Staff Roster (dated 01/21/26), Resident roster (dated 1/14/26) (R1’s), Physician Report (dated 03/13/24), Admission Agreement, Unusual Incident Report (Dated 03/05/2024), and other pertinent records associated with this complaint.

(Evaluation Report continues LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

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 4

Control Number 18-AS-20230303101603

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: MONTE VISTA MANOR	FACILITY NUMBER: 374604144
	VISIT DATE: 02/12/2026

NARRATIVE

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Allegation #1: Staff do not let residents come out of their rooms.

The complaint alleged that the caregivers instructed them not to leave their rooms until they were called for meals and that staff would come to get them. On 02/12/26, the LPA arrived at this facility and observed three residents seated in the dining room. On the same day, the LPA interviewed the Administrator (A1), who denied the allegation and stated that all residents may leave their rooms if they choose. Additionally, on 02/12/26, the LPA interviewed two staff members, #1-2 (S1-S2), who both denied the allegation and explained that residents in wheelchairs are permitted to leave their rooms with staff assistance if they wish. The LPA also interviewed three residents, #1-3 (R1-R3), all of whom denied the allegation and stated that they leave their rooms at will. At the same time, the LPA spoke with one witness (W1), who also denied the allegation and mentioned that W1 visits the facility often and that R1 was always out of R1’s room.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation #2: Staff yell at residents in care.

The complaint alleged that staff raise their voices and yell at the residents. On 02/12/26, LPA interviewed the Administrator (A1), who denied the allegation and stated that staff were trained not to yell at residents, even if residents could not hear staff. Some staff members speak loudly because they believe the residents didn’t hear them, but not in a yelling tone.

Report Continued on LIC9099C

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20230303101603

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: MONTE VISTA MANOR	FACILITY NUMBER: 374604144
	VISIT DATE: 02/12/2026

NARRATIVE

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On 02/12/26, LPA interviewed three residents #1-3 (R1-R3), all of whom denied being yelled at by any staff. On the same day, LPA interviewed the witness (W1), who denied the allegation and stated that W1 visited the facility often. W1 would have noticed the yelling.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is Unsubstantiated.

Allegation #3: Staff does not provide proper toileting assistance to residents in care.

The complaint alleged that staff failed to assist with toileting when called for help at night and stated, “You should go in my diaper.” On 02/12/26, LPA interviewed the Administrator (A1), who denied the allegation and said that some residents wear diapers and staff check residents at night to ensure they are changed. On 02/12/26, LPA Richard interviewed two staff members, #1-2 (S1-S2). Both denied ever failing to change a resident's diaper at night or assisting them out of bed. They also stated that they routinely check each resident at night and change residents' diapers three times a day, or earlier upon request. On 02/12/26, LPA interviewed three residents, #1-3 (R1-R3), all of whom denied the allegation and said they had been changed out of their diapers at night. R1 also stated that R1 likes how the staff treats R1. On 02/12/26, LPA interviewed one witness, W1, who denied any issue with staff assisting R1 daily. W1 confirmed that the staff provides proper toileting to R1.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20230303101603

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: MONTE VISTA MANOR	FACILITY NUMBER: 374604144
	VISIT DATE: 02/12/2026

NARRATIVE

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On 02/12/26, LPA interviewed one witness, W1, who denied any issue with staff assisting R1 daily. W1 confirmed that the staff provides proper toileting to R1. On 02/12/26, LPA reviewed facility notes and Unusual Incident Reports related to this allegation and found no documentation. On 02/12/26, LPA observed staff assisting residents throughout the day.

Based on observations, interviews, and records review (s), the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were cited.

An exit interview was conducted, and a copy of the report was provided to the Administrator Vesna ILICH

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

LIC9099 (FAS) - (06/04)

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