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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 09/30/2021
Date Signed: 09/30/2021 02:16:26 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: 124DATE:
09/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Executive Assistant, Lindya Wenny TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) David Cuevas met with Executive Assistant, Lindya Wenny for the purpose of amending report for complaint report (18-AS-20190917100522). LPA Cuevas went over the amended report with staff Lindya Wenny and provided copies of both the amended complaint report as well as this report.

An exit interview was conducted and a copy of all reports was provided to Executive Assistant, Lindya Wenny.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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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