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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 11/24/2020
Date Signed: 11/24/2020 02:45:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MONTCLAIR ROYALE SENIOR LIVINGFACILITY NUMBER:
361800147
ADMINISTRATOR:SANTOS, ANNAMARIEFACILITY TYPE:
740
ADDRESS:9685 MONTE VISTA AVETELEPHONE:
(909) 621-3545
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY:236CENSUS: 84DATE:
11/24/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Anna Marie SantosTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Pauline Beschorner conducted an unannounced visit to this facility to follow up on a Confirmation of Removal Notification. LPA met with Administrator Anna Marie Santos and discussed the purpose of the visit.

The Criminal Record Exemption needed notification letter dated 11/9/2020 was generated to notify the licensee that Latoria J Hicks must not work or be present in the facility licensed by the Department unless a Criminal Record Exemption is granted. LPA discussed the confirmation of removal notice with Santos. LPA was informed that Latoria Hicks was removed from the facility as soon as the letter was received. Santos stated she understands that Latoria J Hicks cannot work, reside or be present in a facility licensed by the Department unless a Criminal Record Exemption is granted.

During this visit, LPA requested that Santos fill out the Confirmation of Removal Form to confirm that the mentioned staff person does not work, reside nor is present in any licensed facility.

Based on evidence obtained during today’s visit, LPA has verified the individual is not present, employed or residing at the facility. LPA advised Santos to ensure this individual is disassociated from their roster and a roster of employees was submitted to LPA Beschorner.

An exit interview was conducted and a copy of this report was provided to Administrator Anna Marie Santos. Verification of removal is complete.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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