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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 01/31/2020
Date Signed: 09/30/2021 02:18:41 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
09/17/2019 and conducted by Evaluator David Cuevas
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20190917100522
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: 133DATE:
01/31/2020
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Annamarie SantosTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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9
Facility is not adequately staffed to meet resident's needs.
Staff failed to keep facility free of scabies.
Staff are not ensuring that resident's linens are clean.
Staff are not ensuring that resident's clothing is clean.
INVESTIGATION FINDINGS:
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Please Note: The following is an amended report for facility visit that occurred on 01/31/20.

On 01/31/20 Licensing Program Analyst (LPA) David Cuevas conducted an unannounced visit to the facility to follow up with complaint allegations noted above. LPA identified self and was granted permission to enter. LPA met with Administrator, Annamarie Santos who was informed of the purpose of visit.

During the investigation LPA Cuevas conducted: facility file review, resident record review, staff and resident(s) interviews, and documented observations.

Regarding Allegation #1: Facility is not adequately staffed to meet resident's needs
Information gathered from interviews indicate the facility does not have enough staff to meet the resident's needs. Interviews with 8 out of 8 staff members revealed that staffing gaps occur due to a high turnover rate from employees. Per staff’s statements this creates more workload for staff than they can handle.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
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
09/17/2019 and conducted by Evaluator David Cuevas
COMPLAINT CONTROL NUMBER: 18-AS-20190917100522

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: DATE:
01/31/2020
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:TIME COMPLETED:
01:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained a fractured neck while in care
Facility staff failed to safeguard residents personal belongings
INVESTIGATION FINDINGS:
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13
On 01/31/19 Licensing Program Analyst (LPA) David Cuevas conducted an unannounced visit to the facility to follow up with complaint control #18-AS-20190917100522. LPA identified himself and was granted permission to enter. LPA met with Administrator, Annamarie Santos who was informed of the purpose of visit.

Investigation for above allegation was conducted by Community Care Licensing (CCL) Investigation Bureau (IB). During the investigation the following was condcuted: facility file review, resident record review, staff and resident interviews, observations, and review of pertinent documents.

Regarding Allegation(s): #1 Resident sustained a fractured neck while in care and #2 Facility staff failed to safeguard residents personal belongings.
During the investigation it was identified that R1 had, "previously known C1 fractures. However, it is difficult to determine if any of the fracture fragments of the C1 anterior arch is new." primary physician identify existing fractures to be " old and new" this makes determining if fall occurring in March 2019 was the cause of any new fractures.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 18-AS-20190917100522
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 361800147
VISIT DATE: 01/31/2020
NARRATIVE
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While R1 was place at facility staff reported no previous fall history in records. Furthermore, facility staff reported R1 to be required to wear C-collar on his neck; however, R1 would constantly take it off and misplace it. Based on the insufficient evidence, the allegation(s) of #1 Resident sustained a fractured neck while in care and #2 Facility staff failed to safeguard residents personal belongings is UNSUBSTANTIATED.

No deficiencies given during todays visit.

An exit interview was conducted with Administrator, Annamarie Santos were a copy of this report was discussed and provided
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 18-AS-20190917100522
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 361800147
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2021
Section Cited
CCR
87307(3)(f)
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87307 (3)(f) Personal Accommodations and Services: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (F) Basic laundry service (washing, drying, and ironing of personal clothing).
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Licensee will ensure there is enough staffing to handle the facilities laundry needs by adding additional staff to laundry department. A a new staffing schedule for laundry services must be submitted to CCL by due date before deficiency can be cleared.
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This requirement was not being met as evidenced by Facilities washers and dryers endure a 6-month period in which one of the main industrial dryers used for drying residents’ linens was broken.
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Type B
10/14/2021
Section Cited
CCR
87303(g)(1)
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87307 (3)(f) Personal Accommodations and Services: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (F) Basic laundry service (washing, drying, and ironing of personal clothing).
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Licensee will purchase own laundry equipment for facility or find alternative company that will ensure laundry equipment is in good repair at all times and capable of handling facility laundry needs. Proof of correction must be sent to CCL by provided due date before deficiency can be cleared.
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This requirement was not being met as evidenced by: Facilities washing machines and dryers been in-operable or in need of repair for a prolonged period, as a result residents clean clothing needs were not being met. This posed an immediate health and safety risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 18-AS-20190917100522
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 361800147
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2021
Section Cited
CCR
87411(a)
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87411 (a) Personnel Requirements: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services
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Licensee will conduct a staffing assessment to ensure that all the departments within the facility meet the required staffing needs to provide care and supervision for residents. In addition, a plan must be develop and approved by CCL that addresses staffing gaps that occur do to high turnover rates, heavy workloads, and recruitment and retention of personnel. Plan must be submitted for review to LPA by due date.
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This requirement was not being met as evidenced by: Interviews with staff members revealed that staffing gaps occur due to a high turnover rate from employees. Per staff’s statements this creates more workload for staff than they can handle. This posed an immediate health and safety risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 18-AS-20190917100522
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 361800147
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2021
Section Cited
CCR
87211(2)
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87211(2) Reporting Requirements:(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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Licensee will develop a statement of understanding outlining compliance with regulation in addition to having a departmental meeting communicating reporting requirements to all department heads. Proof of correction must be submitted to CCL due date before deficiency can be cleared..
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This requirement was not being met as evidenced by Facilities failing to report scabies outbreak after first case, as a result 3 other cases developed within the memory unit. This posed an immediate health and safety risk to resident in care.
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Type B
10/14/2021
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met evidence by:
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Licensee will develop and implement a policy that addresses the immediate medical attention needed after a resident has been identified with a contagious condition which can affect the residents and staff at the facility by due date.
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Facility failed to seek timely medical attention for residents R1,R2, R3, and R4. After the first case of scabies was identified by a medical professional, this poses a potential risk to the health , safety, and personal rights of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 18-AS-20190917100522
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 361800147
VISIT DATE: 01/31/2020
NARRATIVE
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LPA was informed that the need for coverage in the memory care unit is constant, as a result to supplement the coverage needed medical technicians are used for both covering caregiving gaps and dispensing medication for a total of 34 resident in care. Additionally, review of staff schedule for the month of September 2019 shows that in the memory unit morning shifts had 3 staff scheduled for coverage on Sundays, Mondays, Wednesdays, Thursdays, and Fridays, and 4 staff scheduled for Tuesdays and Saturdays; However, per documents provided the coverage provided on September 19, 2019 through September 30, 2019 shows inconsistencies with staffing schedules on 9 different dates.

Dates identified in which staff schedule did not match coverage needed are, September 19th 3 staff scheduled 2 covered, September 21st 4 staff scheduled 3 covered, September 22nd 3 staff scheduled 2 covered, September 24th 4 staff scheduled 3 covered, September 27th 3 staff scheduled 2 covered, September 28th 4 staff scheduled 2 covered, September 29th 3 staff scheduled 2 covered , and September 30th 3 staff scheduled 2 covered.
Based on the interviews provided and review of document the allegation of facility is not adequately staffed to meet resident's needs is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.
Allegation #2: Staff failed to keep facility free of scabies

During LPA’s resident files review, LPA identify (4) residents to have had scabies while in care at the facility, resident #1, #2, #3, and #4 (R1, R2, R3, and R4). Statements provided by staff during interviews identified that facilities first scabies outbreak in memory unit was not reported to CCL as they though a single case was not considering an outbreak. As a result, the first resident who contracted scabies then spread it to 3 additional residents within the memory unit.

Based on the evidence, statements, and records review the allegation # 2 of Staff failed to keep facility free of scabies is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.

Allegation #3: Staff are not ensuring that resident's linens are clean

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 18-AS-20190917100522
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 361800147
VISIT DATE: 01/31/2020
NARRATIVE
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During interviews with staff it was communicated that the facilities washers and dryers are constantly inoperable resulting in linens and residents personal clothing not been readily available for use. Per, service request reviewed facility endure a 6-month period in which one of the main industrial dryers used for drying residents’ linens was broken. Per statements made by staff as a result of dryer machine not being available facility was not able to keep up with the demand for residents’ clean linens. Based on the evidence, statements, and record review the allegation #3 Staff are not ensuring that resident's linens are clean is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.

Allegation #4: Staff are not ensuring that resident's clothing is clean

During staff interviews with 4 out of 8 staff, it disclosed that facilities washing machines and dryers have been in-operable or in need of repair for a prolonged period, as a result residents clean clothing needs were not being met. Furthermore, during this investigation documents provided to LPA reflect laundry equipment for the facility to be owned by a third party, who has not been consistent with workorders and repairs needed for their equipment.

Based on the evidence, statements, and record review the allegation #4 Staff are not ensuring that resident's clothing is clean is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.

An exit interview was conducted with Administrator, Annamarie Santos were a copy of LIC 9099, LIC 9099D, and personal rights were discussed and provided.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 8