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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 12/22/2021
Date Signed: 12/22/2021 01:00:26 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: 127DATE:
12/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Araceli SotoTIME COMPLETED:
01:01 PM
NARRATIVE
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On 12/22/21, Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit for the purpose of gathering details for an incident report provided to Community Care Licensing (CCL) on 12/7/21.

Client 1 (C1) reported to their responsible party on 12/4/21 that staff 1 (S1) asked C1 if they wanted to be S1's girlfriend. C1 also reported that S1 lifted their shirt and licked their breast in C1's bathroom. C1 stated that S1 exposed their privates to C1 and asked C1 to have sexual relations which C1 declined. C1 informed the facility staff that this incident occurred the day before a roommate moved in with C1 on 11/30/21, some time between 11/21/21 and 11/27/21.

On 12/9/21, LPA phoned care coordinator Ariceli Soto who stated that the facility interviewed C1 and terminated S1. Soto informed LPA that S1 was the facility's maintenance contractor and not an actual employee. LPA asked Soto whether S1 was fingerprinted as he was present and regularly working in this facility and Soto stated that to her knowledge, S1 was not fingerprinted because he was not an employee.

During today's visit, Soto provided Montclair police department's report from 12/7/21, C1's Identification/Emergency Information sheet, Physician's report, and SOC341 completed by ALW housing program coordinator on 12/6/21, and Soto's report from 12/6/21 through 12/7/21. LPA phoned regional director Jimmy Tang who confirmed that S1 has been working in this facility since July 2021 and was offered employment but refused. Per Tang, S1 only wanted to do side jobs for this facility.

Refer to LIC809D for deficiency cited. An exit interview was conducted where this report, 809D, LIC 811 and appeal rights were provided to Soto.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2021
Section Cited

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Fingerprints and criminal records of individuals in contact with clients; exemptions; criminal records clearances - (C) A third-party contractor retained by the facility if the contractor is not left alone with clients in care.
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This requirement was not met as evidenced by:
Based on interviews and record reviews, the licensee has retained the contractor since July 2021 and allowed the contractor to work alone with residents.
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Licensee shall submit a copy to the Department no later than the end of POC date 12/23/21.

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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: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021
LIC809 (FAS) - (06/04)
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