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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426330
Report Date: 10/06/2026
Date Signed: 10/06/2026 11:31:16 AM

Unfounded


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
09/18/2026 and conducted by Evaluator Ivashia Wright
COMPLAINT CONTROL NUMBER: 18-AS-20260918113451
FACILITY NAME:VISTA MONTANA SENIOR LIVINGFACILITY NUMBER:
336426330
ADMINISTRATOR:MARIA FORKRUDFACILITY TYPE:
740
ADDRESS:155 N. GIRARD ST.TELEPHONE:
(951) 658-2274
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:120CENSUS: 80DATE:
10/06/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Maria ForkurdTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff do not ensure that resident's care needs are met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Ivashia Wright, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Ivashia met with Maria Forkurd, Administrator and explained the purpose of the visit.

On September 18, 2026, Community Care Licensing Division (CCLD) received a complaint alleging Staff do not ensure that resident's care needs are met. During the investigation, the LPA inspected the facility, reviewed R1's records, and conducted interviews with the administrator, resident and witness.

Regarding the allegation that Staff do not ensure that resident's care needs are met; it was reported that Resident 1 (R1) has been non-compliant with treatment.

Cont on LIC9099-C...
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Ivashia Wright
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2026
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 2
Control Number 18-AS-20260918113451
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: VISTA MONTANA SENIOR LIVING
FACILITY NUMBER: 336426330
VISIT DATE: 10/06/2026
NARRATIVE
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Information obtained from Additional Witness clarified that the allegations were intended to be against the skilled nursing home that R1 was previously admitted to. It was also advised that R1 sustained her injuries while living independently and was placed at the skilled nursing home for recovery. Information obtained from Maria Administrator, corroborated the information obtained from the Additional Witness. Maria reported R1 was admitted to the facility with assistance of Welbe Health on September 3, 2026. Maria reported R1 hasn’t missed any of her appointments or treatments since being admitted at the facility.

Based on staff interviews, a review of R1’s medical records, and the confirmation that the allegation was not intended for the facility, the allegation that Staff do not ensure that resident's care needs are met is deemed unfounded. A finding that the complaint is unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report along with LIC811 was provided to Administrator Maria Forkurd.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Ivashia Wright
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2