361800147-10-27-2022-56-AS-EMAN-CKLSC6-20221027134457

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 10/27/2022
Date Signed: 10/27/2022 11:01:06 AM

Substantiated

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
07/12/2022 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220712101447

FACILITY NAME:	MONTCLAIR ROYALE SENIOR LIVING		FACILITY NUMBER:	361800147
ADMINISTRATOR:	SANTOS, ANNAMARIE		FACILITY TYPE:	740
ADDRESS:	9685 MONTE VISTA AVE		TELEPHONE:	(909) 621-3545
CITY:	MONTCLAIR	STATE: CA	ZIP CODE:	91763
CAPACITY:	236	CENSUS: 130	DATE:	10/27/2022
		ANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator Annamarie Santos-Tabila		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Communications to the facility are not being answered promptly.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Melody Brown and Victoria Chitgian met with Administrator Annamarie Santos-Tabila at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 10/27/2022 at 10:30 AM to deliver findings for the allegation listed above. LPAs Brown and Chitgian explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and review of pertinent documentations.

Through the information gathered during the investigation, it was confirmed by documents review and interviews that Communications to the facility are not being answered promptly. It was alleged that on 07/11/2022, the facility would not answer calls from hospital staff to report Resident 1 (R1) status. LPA Brown initiated the investigation on 07/15/2022. Interviews with staffs indicated knowledge of the implemented Facility Directive to Night/NOC Shift Medical Technicians (Medtech) that
*** Continuation on LIC9099 ***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

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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Control Number 56-AS-20220712101447

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: 10/27/2022

NARRATIVE

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“Medtechs must make sure to transfer the facility calls to their cellphone.” Interviews with staffs also confirmed that all facility calls at night is the responsibility of the Night/NOC Shift Medtech. Interview with Administrator Annamarie Santos-Tabila (S1) last 10/14/2022 also confirmed that all Medtechs were properly trained and informed of their task/responsibility of answering all calls at the facility during Night/NOC Shift. S1 also said "I am aware of what happened that night and the Medtech on duty that time no longer works at the facility."

Based on interviews and records review, the allegation of Communications to the facility are not being answered promptly is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted and a copy of this report, LIC9099, LIC9099D and Appeal Rights were discussed and provided to Administrator Annamarie Santos-Tabila..

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20220712101447

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: 10/27/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/03/2022 Section Cited CCR 87468.1(a)(9)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have ... (9) To have communications to the... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated to train all Medtech staff in CCR 87468.1(a)(9) and will submit Training Log to LPA Brown by POC due date. Licensee will submit a Statement of Understanding on CCR 87468.1(a)(9) to LPA Brown by POC due date.
	8 9 10 11 12 13 14	Based on interview and records review, the Licensee did not comply with the section cited above by not having a staff answer facility telephone calls from the hospital involving R1 the night of 07/11/2022. This poses a potential Health and Safety risk to the resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC9099 (FAS) - (06/04)

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