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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 12/06/2021
Date Signed: 12/06/2021 12:21:16 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
11/29/2021 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211129084328
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: 126DATE:
12/06/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Araceli Soto - Care CoordinatorTIME COMPLETED:
12:27 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Administrator does not respond to resident's representative.
Staff do not assist resident with incontinence's needs.
Residents room is malodorous.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Anna Bueno and Rohit Lama conducted an unannounced visit to this facility to investigate and deliver findings on the above allegations. LPAs met with care coordinator, Araceli Soto and advised them of the purpose of today's visit. The investigation consisted of interviews and review of pertinent documents.

Allegation 1: Administrator does not respond to resident's representative. Interviews revealed that resident 1 (R1) is able to communicate their needs to staff. LPAs observed R1 speaking to several staff. Allegation 2: Staff do not assist resident with incontinence needs. Interviews revealed that the facility changes diapers every two hours. LPAs interviews and observations reveal that R1 needs moderate assistance toileting while resident 2 (R2) bathing are provided by another vendor. Allegation 3: Residents room is malodorous. Interviews show that resident rooms are cleaned daily and have scheduled thorough cleaning weekly. R1 stated that they ask housekeeping staff to clean their personal items as needed.

Based on today's investigation, LPAs finds that the complaints are UNSUBSTANTIATED. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with and a copy of this report was provided to Ariceli Soto.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
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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