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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 03/21/2022
Date Signed: 03/21/2022 02:42:17 PM


Document Has Been Signed on 03/21/2022 02:42 PM - It Cannot Be Edited

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
, 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:
03/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Araceli SotoTIME COMPLETED:
02:46 PM
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Licensing Program Analysts (LPA) Anna Bueno and Rayshaun Nickolas conducted an unannounced visit to the facility to conduct additional interviews and gather documents pertinent to complaint control number 18-AS-20220105101235. LPAs were met by Care Coordinator Araceli Soto.

LPAs toured the facility, conducted resident and staff interviews, and reviewed facility files. During this visit, LPAs did not observe imminent health & safety concerns.

Ms. Soto was advised that the investigation is still open. Additional time is needed to complete this investigation.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to Ms. Soto.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
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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