360909015-6-16-2021-18-AS-RLAY-C4GL3A-20210630082333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 360909015
Report Date: 06/16/2021
Date Signed: 06/16/2021 12:07:31 PM

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
06/08/2021 and conducted by Evaluator Pauline Beschorner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210608145911

FACILITY NAME:	MONTCLAIR GUEST HOME I		FACILITY NUMBER:	360909015
ADMINISTRATOR:	DINA MOPERA		FACILITY TYPE:	740
ADDRESS:	4515 ORCHARD STREET		TELEPHONE:	(909) 624-5575
CITY:	MONTCLAIR	STATE: CA	ZIP CODE:	91763
CAPACITY:	24	CENSUS: 0	DATE:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Miriam Meyers		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility has pests.
Facility does not safeguard resident(s) personal property.
Facility is not clean.
Facility is in disrepair.
Resident(s) not accorded dignity in relationships with staff.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pauline Beschorner made an unannounced visit to the facility to investigate the above mentioned allegations. LPA met with caregiver Miriam Meyers.

Based on an interview conducted with caregiver Meyers it was found that the complaint received is regarding Montclair Guest Home II. LPA confirmed that there are no residents residing at this facility at this time.

This agency has investigated the above mentioned allegations and we have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted and a copy of this report was provided to caregiver Miriam Meyers.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline Beschorner	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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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