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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 12/02/2020
Date Signed: 12/08/2020 02:41:39 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
08/13/2020 and conducted by Evaluator Pauline Beschorner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200813082342
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: 109DATE:
12/02/2020
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Anna Marie SantosTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility staff failed to meet the hygiene needs of the resident
Staff neglect resulting in resident developing pressure injury
Staff are not ensuring resident linens are clean
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pauline Beschorner conducted this investigation visit telephonically to conclude this agency’s investigation into the complaint allegations mentioned above. LPA spoke with Administrator Anna Marie Santos.

During this investigation, interviews were conducted with the Administrator, staff and independent witnesses. Resident 1’s (R1) Physician Report, Admission’s Agreement and other pertinent documentation was requested and reviewed. LPA was unable to interview R1.

The first allegation alleges facility staff failed to meet the hygiene needs of the resident. A review of facility records revealed that R1 was bathed twice a week. Interviews with staff revealed that R1, at times, would refuse to be bathed. When this happened staff would submit a refusal sheet to the Administrator. One refusal sheet was provided and reviewed showing that resident refused to be bathed on 5/10/2020. CONTINUED ON NEXT PAGE
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/13/2020 and conducted by Evaluator Pauline Beschorner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200813082342

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: 109DATE:
12/02/2020
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Anna Marie SantosTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not ensuring residents clothing is clean
Emergency Call Button not within reach of resident
Staff unable to meet the needs of bedridden resident(s)
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pauline Beschorner conducted this investigation visit telephonically due to Covid-19 to conclude this agency’s investigation into the complaint allegations mentioned above. LPA spoke with Administrator Anna Marie Santos.

During this investigation, interviews were conducted with the Administrator, staff and outside sources. Resident 1’s (R1) Physician Report, Admission’s Agreement and other pertinent documentation was requested and reviewed. LPA was unable to interview R1.

The first allegation alleges staff are not ensuring residents clothing is clean. Interviews with relevant parties revealed R1’s clothing was soiled with dirt and resident would wear soiled clothing. Interviews with staff revealed R1’s family would pick up R1’s clothing to be washed on a regular basis to ensure residents clothing got washed. A review of residents Admission’s Agreement shows that R1’s family would provide the laundry for R1 to ensure that clothing was clean. CONTINUED ON NEXT PAGE
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20200813082342
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: 12/02/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
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26
27
28
29
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31
32
Based on the information provided, this allegation is unfounded as the family was providing the laundry services for R1 to ensure R1’s clothing was clean.

The second allegation alleges staff were unable to meet the needs of bedridden resident. Interviews with pertinent parties revealed that R1 needed to be repositioned and turned and could not independently transfer to and from bed. A review of staff records indicated staff have been trained to care for bedridden residents. An interview with the Administrator stated that the facility does not use a Hoyer Lift to assist residents as it is a liability on the facility. A review of R1’s file indicated that an Appraisal Needs and Services Plan was updated on March 22, 2020 to reflect that R1 was bedridden and required assistance in turning and repositioning in bed and transfer to and from bed. Interviews with staff and review of records indicated that R1 was repositioned every 2 hours. LPA could not find any evidence that staff were unable to meet the needs of bedridden resident.

The third allegation alleges Emergency Call Button is not within reach of resident. Interviews with staff revealed that during the 2-hour checks the staff would ensure that the call button was within reach of R1. All rooms have the call button near the headboard of the bed. The call button sits above the headboard about shoulder height to the resident, and about six inches from the headboard. The emergency call button has a pull string that dangles about 12" from the unit. The unit is accessible and reachable to all residents. Interview with Administrator revealed that Administrator went into R1’s room and placed a sock over the call button so that R1 could easily detect and pull the call button as needed. LPA could not find any evidence that the call button was ever out of reach of R1.

This agency has investigated the above-mentioned complaints. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was reviewed with and provided to Administrator Anna Marie Santos, whose signature on this form confirm receipt of the above-mentioned documents.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 18-AS-20200813082342
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: 12/02/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
No other documentation was provided to show that R1 refused to be bathed. Interviews with independent witnesses revealed that residents are clean and hygiene needs are met. Not all relevant parties were able to be interviewed therefore LPA was unable to corroborate that staff failed to meet the hygiene needs of R1.

The second allegation alleges staff neglect resulted in resident developing a pressure injury. A review of Home Health records indicated on August 19, 2020; ComCare Home Health received a referral for services. On August 20, 2020 ComCare Home Health went out to the facility to conduct an evaluation and observed the wounds and completed a referral to authorize Home Health Services. Treatment by ComCare Home Health began on the same day, August 20, 2020 with subsequent visits continuing every other day thereafter until the wounds were healed. According to interviews, R1 and facility staff were instructed to have R1 remain in bed but to rotate positions to relieve pressure from affected areas. Facility records indicated that resident was turned in bed every 2 hours during the safety check. Interviews with staff revealed that R1 was turned every 2 hours. Based on observations of the records it is unclear when staff may have notified the Med Tech or Administrator about R1’s skin breakdown. LPA is unable to corroborate that R1 developed a pressure injury due to staff neglect as not all relevant parties were available to be interviewed.

The third allegation alleges staff are not ensuring that resident linens are clean. Interviews with independent witnesses revealed that witnesses have never gone to the facility and observed that R1’s linens were not cleaned. Interviews with staff revealed a bed bath is given to R1 2 times/week, and at that time R1’s linens were changed as well. R1 is also changed every 2 hours so if there was a need for a linen change the staff would change the linens during that time. The bed sheets get changed on average 3 to 4 times/week. Not all relevant parties were able to be interviewed therefore LPA was unable to corroborate that staff were not ensuring that resident linens were clean.

Although the above-mentioned allegations may have happened, or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are deemed UNSUBSTANTIATED at this time.

An exit interview was conducted, and a copy of this report was reviewed with and provided to Administrator Anna Marie Santos, whose signature on this form confirm receipt of the above-mentioned documents.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4