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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 05/06/2022
Date Signed: 05/06/2022 02:13:15 PM

Unsubstantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/18/2022 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220318083750
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: 130DATE:
05/06/2022
UNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Mikaila Tonan, receptionistTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff did not administer resident's medication as prescribed.
Staff did not provide adequate food service.
Resident was not provided clean linen.
Staff did not safeguard resident's personal items.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to deliver findings on the above allegations. LPA met with Mikaila Tonan, receptionist. The investigation consisted of file review, interviews with relevant parties, and observations of the facility.

Allegation 1: Staff did not administer resident's medication as prescribed. The investigation revealed that while Resident 1 (R1) was being given medication, R1 will sometimes not take the medication. Also, it was revealed that R1 is ambulatory and self responsible. Allegation 2: Staff did not provide adequate food service. The investigation revealed that R1 does not have a special diet. This facility provides a modified menu for residents with dietary restrictions. Allegation 3: Resident was not provided clean linen. Interviews reveal that R1 had purchased their own linens. Also, LPA verified that the facility has a supply of clean linen labeled with the facility’s name and residents are also able to use their own purchased linens. Allegation 4: Staff did not safeguard resident's personal items. LPA was able to verify the facility’s policy to have residents label their belongings. LPA was unable to find corraborating evidence relative to this complaint.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time. An exit interview was conducted where this report was discussed and provided to Mrs.Tonan.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
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 4
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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/18/2022 and conducted by Evaluator Anna Bueno
COMPLAINT CONTROL NUMBER: 56-AS-20220318083750

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: 130DATE:
05/06/2022
UNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Mikaila TonanTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to deliver findings on this allegation. LPA met with Mikaila Tonan, receptionist. The investigation consisted of file review, interviews with relevant parties, and observations of the facility.

The above allegation is illegal eviction. LPA reviewed relevant documentation including eviction notices, communications between facility staff and with R1’s outside party case worker, Resident's (R1) admissions agreement, incident reports, and photographic evidence related to R1 facility incidents. The 30-day eviction letter states that the reason for eviction is because R1 failed to comply with general policies of the facility. Per Care Coordinator, R1 refused to cooperate with the facility and outside case worker in seeking new medical re-evaluation necessitated by increasing incidents within the facility. Additionally, R1 was placed on a psychiatric hold due to incidents that occurred in the facility.

In the process of returning from R1's psychiatric hold, the facility served R1 with a three day notice of eviction. Additionally, the facility subsequently filed a restraining order against R1 and R1 was unable to return to the facility. This poses an immediate health and safety risk to the residents in care.

******CONTINUED ON LIC-9099C*****
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20220318083750
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
, CA 92507

FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING
FACILITY NUMBER: 361800147
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2022
Section Cited
CCR
87224(b)
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The licensee may, upon obtaining prior written approval from licensing agency, evict the resident upon 3 days written notice to quit. The licensing agency may grant approval for eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior which is a threat to the mental and/or physical health or safety of himself or...others in the facility.
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Licensee and staff shall review regulation section 87224. A statement of understanding of the regulations shall be provided to CCL by end of POC due date 5/9/2022.
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This requirement was not met as evidenced by:

The Department did not receive eviction notices until complaint #56-AS-20220318083750 was filed and investigated.
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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) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20220318083750
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
, CA 92507
FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING
FACILITY NUMBER: 361800147
VISIT DATE: 05/06/2022
NARRATIVE
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The allegation of illegal eviction is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC-9099D. Refer to LIC-9099D for deficiency cited.

An exit interview was conducted where this report, LIC-9099D, and Appeal Rights were discussed and provided to Mrs. Tonan.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4