Vista Del Monte

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Upon arrival, LPA was greeted by Administrator Douglas Tucker who was immediately available to participate in the inspection. LPA explained the purpose of the visit. Entrance interview conducted. The facility is a Continuing Care Retirement Community (CCRC) licensed for 266 residents who are 60 years old or older of which 147 residents may be non-ambulatory, and 28 may be bedridden. The facility has a hospice waiver for twenty (20) residents. Currently, there are thirteen (13) residents on hospice and zero bedridden residents. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. The facility consists of 8 separate buildings, including a memory care resident unit, assisted living resident unit, an independent living unit, fitness & aquatic center, and a building combining a library, patio room, main dining room, main lounge, and the administration offices. The facility also houses a wellness clinic within the memory care unit and a corner store within one of the independent living buildings. The facility’s Fitness and Aquatic Center provides exercising, fitness classes, fall prevention classes, balance classes, seated martial arts, pool volleyball, and physical therapy inside and outside the pool. Please continue to 809-C, Pg 2. Artwork including photography classes, Ted Talks, poetry reading, music, meditation, religious services, special celebrations, happy hour, lawn exercise, Pilates, games, and movies are provided in various common areas of the facility. Residents may participate at will on excursions to local beaches, parks, museums, and special excursions outside the immediate area. The facility has a main kitchen for residents of the facility in the main dining room building. The kitchen area was observed to be clean and in good working condition. LPA observed enough perishables for 2 days and non-perishables for 7 days for all residents in care. The physical environment was checked for cleanliness and condition. The facility was seen to be in good repair inside and outside. Fire inspection was current as of 1/29/2026. Personnel records were reviewed for health screening, trainings, and required hiring information. Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Services Plans, and Medication Administration Records (MARs). Medication inventory revealed dates of administration of medications could not be verified as no start date was documented and an accurate medication count could not be confirmed. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Exit interview conducted. A copy of the report and appeal rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Jun 30, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Upon arrival, LPA was greeted by Amy Ross, Director of Resident Services. Administrator Douglas Tucker was immediately available to participate in the inspection. LPA explained the purpose of the visit. Entrance interview conducted. The facility is a Continuing Care Retirement Community (CCRC) licensed for 266 residents who are 60 years old or older of which 147 residents may be non-ambulatory, and 28 may be bedridden. The facility has a hospice waiver for twenty (20) residents. Currently, there are seven (7) residents on hospice and zero bedridden residents. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. The facility consists of 8 separate buildings, including a memory care resident unit, assisted living resident unit, an independent living unit, fitness & aquatic center, and a building combining a library, patio room, main dining room, main lounge, and the administration offices. The facility also houses a wellness clinic within the memory care unit and a corner store within one of the independent living buildings. The facility’s Fitness and Aquatic Center provides exercising, fitness classes, fall prevention classes, balance classes, seated martial arts, pool volleyball, and physical therapy inside and outside the pool. Please continue to 809-C, Pg 2. Artwork including photography classes, Ted Talks, poetry reading, music, meditation, religious services, special celebrations, happy hour, lawn exercise, Pilates, games, and movies are provided in various common areas of the facility. Residents may participate at will on excursions to local beaches, parks, museums, and special excursions outside the immediate area. The facility has a main kitchen for residents of the facility in the main dining room building. The kitchen area was observed to be clean and in good working condition. LPA observed enough perishables for 2 days and non-perishables for 7 days for all residents in care.. The physical environment was checked for cleanliness and condition. The facility was seen to be in good repair inside and outside. Fire inspection was current as of 4/17/2025. Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Medication Administration Records (MARs). All persons associated with the facility have completed a criminal record clearance. Administrator certificate is valid. Due to time restraints, LPA will return at a later date to continue the inspection. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Jul 22, 2025

Allegation investigated: Facility staff did not meet the resident's needs.

On 03/04/2025, Licensing Program Analyst (LPA) Garrett Haner-Tomasko and Licensing Program Manager (LPM) Kelly Burley conducted an initial complaint visit to investigate the above allegation. LPA met with Administrator Douglas Tucker and explained the purpose of the visit. During the visit from 10:15am to 3:00pm, LPA and LPM interviewed administrator, staff, private caregivers, residents, visitors, and obtained relevant documents. On the allegation: Facility staff did not meet resident's needs. The investigation revealed on one occasion over a holiday weekend, Resident 1 (R1) was found on the floor, still in their pajamas around 9:30am, had not had breakfast, and was soiled. Interviews revealed on 2/17/2025, a registry staff was on shift and was not aware of R1’s typical schedule to get up around 6:30am-7am, earlier than some residents. Most residents wear pendants that detect falls and alert staff. (Continued 9099-C) Substantiated However, R1 slid out of bed so there was no fall detected and no alert. This was the first time R1 slid out of bed, however it has happened twice more following this incident. R1’s private caregiver provided care to R1, and R1’s family and physician were notified. Per the care plan R1 is to be checked on during the night three times by staff. Care Services Manager (CSM) reminded all staff during shift change of R1’s specific and different routine, to ensure R1’s needs were met in the future. CSM stated service plans that are printed in the break room would be on updated to include preferred times of care, rather than just the care needed. CSM stated a care meeting was held 3/4/2025 with facility staff and R1’s health advocate. CSM discussed fall mitigation options such as a hospital bed, floor mat, hip pads, and using a Purewick system. Interviews indicated this was the only time R1 was found like this. Other residents interviewed indicated their needs were met. Based on the information obtained, the allegation is deemed Substantiated at this time. Exit interview, technical violated issued, copy of report given, appeal rights given.the state’s words, verbatim · CDSS document, Mar 4, 2025 · control 29-AS-20250225143815

Type of visit: Required - 1 Year

On 07/29/2024 Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced for an unscheduled visit to conduct a required annual site inspection at the facility above. The LPA was greeted by Administrator Douglas Tucker and informed them of the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE) comprised of 8 separate buildings, including a memory care resident building, assisted living resident building, fitness & aquatic center, 4 independent living resident buildings, and a building combining a library, patio room, main dining room, main lounge, and the administration offices. The facility also houses a wellness clinic within the memory care building and a corner store within one of the independent living buildings. The facility is licensed for a maximum 266 residents who are 60 years of age or older. 147 of the residents may be non-ambulatory, 91 ambulatory, and 28 bedridden. The facility has both Dementia Waiver and a Hospice Waiver for 20 residents. At the time of the annual inspection, a COVID-19 infectious disease outbreak that began 07/25/2024 had four (4) residents and no staff testing positive, which was reported to the Licensing Agency and Public Health Agency. KITCHEN(S): The facility has a main kitchen for residents of the facility in the main dining room building. There are also individual kitchen areas in the memory care segment of the facility and the assisted living segment of the facility. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in the kitchen are inaccessible to residents. Kitchen appliances were in operable condition and looked clean/in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last a week or more. Additional perishable food items were maintained on a shelf and/or an extra freezer. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation. Heating devices such as stoves are inaccessible to residents, as are sharps/other items that could constitute a danger to residents. Continued on 809-C All the kitchen locations in the facility were clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerators were all in the appropriate temperate Fahrenheit. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. COMMON AREAS: At the time of the visit, the main lounge and dining room were observed to be appropriately furnished, with all furniture in good condition. There is a lounge area for residents off of the main dining room and main lounge that is appropriately furnished, with all furniture being in good condition. There are multiple fireplaces on the premises, which were all covered and inaccessible. There are pianos in the common areas of the facility in good repair and operating condition. The facility maintained a comfortable temperature in all 8 separate buildings inspected. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit in each of the buildings inspected. The fire extinguishers in all buildings inspected by LPA were fully charged and were last serviced annually. The LPA observed required postings throughout all common spaces including Resident Personal Rights and Resident Council Rights. There are activity supplies and equipment, including reading materials for the residents in all common areas inspected. All window screens were in good repair in all of the buildings comprising the facility. There is appropriate lighting in all of the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all stairways are well-lit with sturdy hand railings/stair chair accessibility devices. As the facility has more than 16 residents and is multiple stories, there is a signal system in place which was functional at the time of the inspection by the LPA. OUTSIDE/LAUNDRY/MISCELLANEOUS: The facility is comprised of 8 separate buildings for multiple uses, with garages for independent living residents. There are multiple story buildings at the facility, with evacuation stair chairs at each stairwell. There is a main entrance road into the facility and an Arrival Plaza Kiosk. The facility has walls of concrete surrounding the entrances and exit locations of the facility for resident protection/privacy. The facility has a new outdoor patio area for residents outside of the main dining room and main lounge building. Outdoor activity spaces and the dining patio for residents are equipped with furniture for resident use. The memory care building/segment of the facility has delayed egress entrances/exits. Auditory devices are in place to monitor exits of the memory care building in the facility, if exiting presents a hazard to any resident. All outdoor areas with stairways, inclines, ramps, or open porches have accessibility ramps for residents, are well-lit, and have hand railings/grab bars. Continued on 809-C There is a pool in the fitness and aquatic center building of the facility. The pool/body of water complies with all safety instructions per the regulations. When not in use the aquatic center pool room is locked to prevent resident access and/or the Fitness & Aquatic Center itself is locked to be inaccessible to residents. The pool has appropriate assisting devices including grab bars for residents. This is a facility with over 16 residents, therefore there are multiple designated laundry rooms where cleaning products are stored, which are kept locked. The laundry rooms are accessible through the different segmented buildings in the facility including memory care, assisted living, and independent living. There was emergency food and water in a storage room/area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents. There are multiple first aid kits that include sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport residents are in safe operating condition with appropriate insurance information. BEDROOMS: The facility has resident bedrooms in the memory care, assisted living, and independent living segments/buildings. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are hundreds of designated resident rooms in the facility, with the LPA inspecting multiple rooms in each building that houses residents. The bedrooms for residents differ between shared units with 2 beds per room, and individual units with 1 bed per room. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assistive device such as a wheelchair or a walker. Each room has at the least a chair, nightstand, chest of drawers, and sufficient lighting. Each resident bedroom in the independent living segment of the facility is furnished with a smoke alarm/fire alarm system, emergency call system, and appliances for the residents. RESTROOMS: LPA observed facility restrooms sanitized and in operating condition. There are non-private restrooms in the common areas of the facility as well as private restrooms in the resident’s bedrooms in specific buildings of the facility including independent living. All restrooms inspected by the LPA had assisting equipment for residents including grab bars and/or non-skid surfaces. The bathrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations. There are an adequate number of toilets and tubs/showers per resident in the facility. Night-lights are installed in the hallways outside of the common area restrooms. Continued on 809-C INFECTION CONTROL: Upon entry to each building, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate isolation rooms if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. The facility maintains a COVID-19 Health Care System Mitigation Playbook from the California Department of Public Health as well as an Emergency Preparedness Informational Form and Interim Guidance for Outbreak Management in Long-Term Care and Post-Acute Care Facilities. The facility maintains an Infection Control Plan as well as an Emergency Operations Program and Plan Manual with aspects pertaining to infection control. On 07/25/2024, the facility notified Licensing Agency and Public Health of Infectious Disease Outbreak of COVID-19. Four (4) residents and no staff tested positive so far. LPA observed all appropriate measures regarding a COVID-19 outbreak being observed including isolation, masking, and notice to visitors. RECORDS/MEDICATIONS: LPA reviewed Facility Records compromising Staff member files for LIC 501 personnel records, LIC 503 health assessments with Tuberculosis (TB) test results, Personnel Action Notice, Job Description with date of employment, LIC 9052 Employee Rights, LIC 508 criminal record Statements, criminal record clearances, first aid/CPR certification that is not expired, and the appropriate training. The administrator of the facility has an active Residential Care Facility for the Elderly (RCFE) administrator certificate that expires on 05/18/2025. Additionally, Resident records reviewed for LIC 603 Pre-Admission/Placement appraisals, LIC 602 Physicians Reports, Consent Forms, Personal Rights for Residents, LIC 601 Emergency Information, LIC605A Release of Medical Information, PRN Authorization, Needs and Services Plan (ANS), Resident Assessments, Mini-Mental State Exam (MMSE) for residents with dementia, Self-management of medications if applicable, Medication Orders, Medication Logs, Advance Directives, Conservatorship Documentation, and Physician Orders for Life-Sustaining Treatment (POLST). Facility medications were audited by LPA for a locked centralized storage area for resident medications as well as the Centrally Stored Medication and Destruction Record for residents. FACILITY DOCUMENTATION: LPA observed required postings throughout the facility. Provider Information Notices are easily accessible and presented to LPA upon request during inspection process. No deficiencies cited. Exit interview conducted. A copy of the report was issued to the facility.the state’s words, verbatim · CDSS document, Jul 29, 2024

Allegation investigated: Staff charged resident a fee not listed in the admission agreement

Licensing Program Analyst (LPA) Melisa Rankin conducted an unannounced subsequent complaint visit to the facility above to issue final findings. LPA arrived at the facility, met with Douglas Tucker, and announced the purpose of the visit. On the allegation: Staff charged resident a fee not listed in the admission agreement. It is alleged that a monthly bill from the facility to a resident was paid on time. However, the facility indicated that the payment was received months late and charged the resident a bill for a late charge fee as well as a late charge interest fee. It is alleged that due to the mistaken late fee, the resident officially has a late payment on their records which should also be removed. Continued on 9099-C Unsubstantiated On 03/20/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a facility site visit from 10:30am to 12:30pm to investigate the complaint allegation. During this investigation visit, LPA interviewed Staff, Resident(s), and conducted record review of requested and received facility documentation pertinent to the allegation in the complaint. LPA received and reviewed the Schedule of Monthly Fees for the facility which indicates what is included in the monthly fee, and additional fee services available. LPA conducted record review of the resident admission agreement with the facility which details resident fees. According to the admission agreement on late fees, if monthly fees are not paid in full on or before the fourteenth (14th) day of the month, the resident agrees to pay a late fee of $50.00 per delinquent monthly invoice. Additionally, any monthly fees which are not paid with fourteen (14) days after the date they are due shall bear interest at maximum legal rate from the due date until paid. LPA requested and received a copy of the facility Resident Handbook, that includes a section for residents on Billing and Finances. This provides a general overview of the billing process and recourses available to residents. A monthly statement is delivered to a resident on or before the first (1st) of the month, detailing expenses. Through interviews conducted by LPA, staff stated they believe there were erroneous dates for Resident 1 (R1)’s payment as well as incorrect billing Statements. However, a billing statement indicating that the bill was paid on time was never shared with the LPA. Staff interviewed by LPA indicated that any late fee accrued by the resident was waived due to the concerns raised by the resident, but did not admit or state any error made on billing dates or references to incorrect billing statements. On 03/20/2024, LPA received documentation pertinent to the allegation in the complaint investigation. Based on record review, the facility waived all late fees incurred to the resident including the late charge fee as well as a late charge interest fee. As both fees were waived by the facility, no additional fee was charged to the resident. Continued on 9099-C Because the facility waived both fees disputed, the facility did not charge a resident any fee not listed in the admission agreement. Additionally, late charge fees and late charge interest fees are both listed fees in the resident admission agreement. Based on the information obtained, there was Insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 29, 2024 · control 29-AS-20240311113943

Type of visit: Case Management - Other

On 02/15/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced Case Management site visit with the purpose of following up on an immediate exclusion served to Staff #1 (S1) via certified mail. LPA met with Administrator Douglas Tucker and Director of Human Resources Monica Leon for a Confirmation of Removal visit. An immediate exclusion order for S1 was dated February 2, 2024, and provided via certified mail. S1 is excluded from any care facility licensed by the Department and is required to be removed from the facility. Administrator stated that S1 has not worked at the facility since July 2nd, 2022 (07/02/2022). During this visit, the Administrator provided LPA with a copy of the current personnel report to verify S1 is no longer working at the facility. During today’s visit, S1 was not observed in the facility at this time. No citations issued during today's visit. Exit interview was conducted with Administrator, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 15, 2024